Summary minor challenges in women and child healthcare N. Smit - 2023
Summary minor
‘Challenges in Women and Child
healthcare’
Inhoudsopgave
LECTURES WEEK 1.......................................................................................................................................... 2
DEVELOPMENT OF THE FEMALE INTERNAL REPRODUCTIVE ORGANS...................................................................................2
MRKH SYNDROME.................................................................................................................................................2
TRANSPLANTATION OF THE UTERUS............................................................................................................................4
UTERINE ANOMALIES...............................................................................................................................................4
IVF GESTATION.......................................................................................................................................................6
DISORDERS OF SEX DEVELOPMENT.............................................................................................................................7
LECTURES WEEK 2.......................................................................................................................................... 8
THE NICHE/CAESAREAN SCAR DISORDER......................................................................................................................8
THE GREEN OR....................................................................................................................................................11
UTERINE FIBROIDS................................................................................................................................................ 11
NON-SURGICAL FIBROID TREATMENT........................................................................................................................12
TREATMENT OF FIBROIDS........................................................................................................................................13
LECTURES WEEK 3........................................................................................................................................ 13
A GENERAL INTRODUCTION TO SUB-/INFERTILITY........................................................................................................13
SUBFERTILITY: THE MALE FACTOR.............................................................................................................................14
OVULATION DISORDERS..........................................................................................................................................16
FUTURE PERSPECTIVES IN FERTILITY..........................................................................................................................18
ENDOMETRIOSIS...................................................................................................................................................18
TUBAL DISORDERS.................................................................................................................................................19
LECTURES WEEK 4........................................................................................................................................ 20
THE YOUNG PREGNANCY........................................................................................................................................20
GENERAL INTRODUCTION TO TREATMENT OF SHOCK....................................................................................................21
EXTRA UTERINE PREGNANCIES.................................................................................................................................21
MISCARRIAGE......................................................................................................................................................21
ANATOMY OF THE FEMALE REPRODUCTIVE ORGANS.....................................................................................................23
LECTURES WEEK 5........................................................................................................................................ 23
MULTIPLE GESTATION............................................................................................................................................23
HYPERTENSIVE DISORDERS IN PREGNANCY.................................................................................................................25
SILDENAFIL THERAPY IN DISMAL PROGNOSIS EARLY-ONSET IUGR (STRIDER)...................................................................27
SCREENING AND DIAGNOSIS OF FGR........................................................................................................................27
METABOLIC SYNDROME.........................................................................................................................................29
MANAGEMENT AND PROGNOSIS OF HYPERTENSIVE DISORDERS AND FGR........................................................................30
LECTURES WEEK 6........................................................................................................................................ 31
PERINATAL MORTALITY AND PERINATAL AUDIT.............................................................................................................31
,Summary minor challenges in women and child healthcare N. Smit - 2023
Lectures week 1
Development of the female internal reproductive organs
Pregnancy starts with the first day of the last menstrual cycle. Fertilization is about two
weeks later. Week 2 – week 10 is the embryonic period. From 10 weeks it is called the fetal
period. Fetal viability is from 24 weeks, this also makes 24 weeks the ultimate date for an
abortion.
Embryonic period
The embryonic period is counted from the moment of fertilization. A woman who is pregnant
for 8 weeks, has an embryo of 6 weeks old. After 3 weeks of embryonal development (GA 5
weeks) a three-layered germinal disc has formed consisting of the ectoderm, endoderm, and
mesoderm. The embryonic period is counted in 23 carnegie stages, because you can never
know exactly when natural fertilization took place. A pronephros has never been found in
human embryos. the embryonic period is clinically not relevant, because abnormalities are
visible with an ultrasound and thus in the fetal period.
MRKH syndrome
MRKH syndrome is characterized by a congenital absence of the uterus and the upper part of
the vagina. The etiology is mostly unknown. The reproductive abnormalities are due to
incomplete development of the Müllerian duct. This structure in the embryo develops into
the uterus, fallopian tubes, cervix, and the upper part of the vagina. The ovaries are present.
Endocrinologically FSH/LH/estrogens are normal, just as the secondary sexual
characteristics (mammae).
Diagnosis mostly in puberty due to primary amenorrhea. This is defined
as no menarche before 16 years old or 5 years after the
thelarche (breast development)
Karyotype 46XX with a normal fenotype
Hypothesis autosomal dominant inheritance with sex-limited (female)
expression and incomplete penetrance
Besides this, other abnormalities have been recorded. 30-50% of the patients have
abnormalities in their uropoetic tract, such as a renal agenesis, horseshoekidney and a pelvic
kidney. 20-40% has skeletal problems, <10% hearing problems ans <10% cardiac problems.
This is caused by the development of the skeleton, kidneys, and hearing all at the 6th week.
Type 1 MRKH typical type, 44%. Uterus and upper 2/3 part of the vagina is missing.
,Summary minor challenges in women and child healthcare N. Smit - 2023
Type 2 MRKH atypical type, 56%. Uterus, upper 2/3 part of the vagina AND ≥ 1 additional
malformation. Also known as MURCS.
The ovaries produce estrogen, the uterus has no role in the production of female hormones,
thus you can explain to a patient she ‘is still female’ with this diagnosis. Penetration is not
possible, but she can still have a clitoral orgasm.
Treatment of MRKH; neovagina/vaginal reconstruction
Non-surgical treatment
The non-surgical way to create a neovagina is with dilatation of the existing vaginal cavity.
Either with dilators or through sexual intercourse with penetration. Franks’ method is dilating
1-3 times a day for 10-30 minutes. Important to first push downwards so that the skin of the
ureter is not pulled. Requires a lot of motivation and support. In about 6 months a depth of 6
centimeters can be reached. Success rate of 90-95%. A complication is a prolaps.
Surgical treatment
Several surgical techniques to reconstruct a vagina. Most frequent used procedure is
Vechietti. This procedure creates a neovagina through continuous invagination of the vaginal
dimple by an olive-shaped vaginal dilator. The vaginal “olive” is connected to a spring-loaded
tensioning device on the patient's abdomen via laparoscopically placed sub-peritoneal
sutures. The sutures are tensioned by 1-1,5 cm each day over the course of 5 to 7 days. Quick
result, good lubrication and result of 90-94%.
Another procedure is Davydov. It is a three-stage procedure that requires dissection of space
between the urethra, bladder, and rectum, followed by peritoneal mobilization which is
subsequently sutured to the edges of the vaginal vestibulum. It also requires postoperative
dilation and is suitable for women who underwent extensive pelvic surgeries.
Mclendoe either uses a split or full thickness skin graft. This graft is wrapped around a mould
and placed in situ for 1-2 weeks. Negative aspect is the vaginal hairgrowth, this can be
reduced via lasertherapy. Less lubricated.
, Summary minor challenges in women and child healthcare N. Smit - 2023
Last technique is the sigmoid technique. Part of the sigmoid with its vascular pedicles is
removed via laparotomy and repositioned to form a vagina.
Neovaginas are not SOA proof, but there are no ascending infections possible.
Transplantation of the uterus
A uterus transplantation is possible when a person has an absolute uterine factor infertility
(AUFI). For example people with MRKH, severe congenital uterusanomalies and after a
hysterectomy. For transwomen (MF) it is not yet an option, but it might be in the future.
Alternatives for uterus transplantation in NL are high-technological surrogacy
(hoogtechnologisch draagmoederschap), adoption and fostercare.
The surgery of the donor costs about 10-13 hours, the recipients’ about 4-5 hours.
MRKH women after a uterus transplantation already had an ovulation, nothing will
change about this. Did not menstruate in the first place, but the new uterus will respond
directly on the females’ hormones and the endometrial development. The first menstruation
will take place after 1-2 months. Natural gestation is not possible, as the fallopian tubes are
not connected IVF necessarily (IVF process must be started on forehand).
Transmen as donors is not always possible if wanted, because their uterus is smaller due to
hormone suppressing on a young age. Therefor the vessel diameter is smaller, and this has to
be as big as possible for a successful transplantation.
Costs
- Adoption: 23.350 (NL)
- Surrogacy: 15.000 (NL)
- Uterus transplantation: 100.000 (NL)
The medical ethics committee has adviced to not perform uterus transplantation in the
Netherlands. Due to scarcity of available recourses, the presence of an alternative for some
patients (HTDM) and the lack of literature studies.
After two births (always a CS) the uterus is removed. Patient otherwise has to be on
immunosuppressives for the rest of their life. Maximum of two due to the scarcity of the
resources and services via IVF.
Uterine anomalies
The reproductive system is embryologically formed out of the mesonefros. The urogenital
tract develops from the mesonephric duct (Wolff), the paramesonephric duct (Muller) and
the urogenital sinus. In absence of AMH/testosterone/in XX the Wolffian duct degenerates
and the Mullerian tract develops the female reproductive tract. Uterine anomalies may form
if the fusion of the Mullerian tracts fails. Because of the embryological history, always think
of renal abnormalities in case of a uterine anomaly.
The ASRM classification is a formerly used classification system to classify the abnormalities
of the uterus and/or cervix. Later the ESHRE/SGE classification was introduced. This
describes what you see per section (uterus/cervix/vagina)
Summary minor
‘Challenges in Women and Child
healthcare’
Inhoudsopgave
LECTURES WEEK 1.......................................................................................................................................... 2
DEVELOPMENT OF THE FEMALE INTERNAL REPRODUCTIVE ORGANS...................................................................................2
MRKH SYNDROME.................................................................................................................................................2
TRANSPLANTATION OF THE UTERUS............................................................................................................................4
UTERINE ANOMALIES...............................................................................................................................................4
IVF GESTATION.......................................................................................................................................................6
DISORDERS OF SEX DEVELOPMENT.............................................................................................................................7
LECTURES WEEK 2.......................................................................................................................................... 8
THE NICHE/CAESAREAN SCAR DISORDER......................................................................................................................8
THE GREEN OR....................................................................................................................................................11
UTERINE FIBROIDS................................................................................................................................................ 11
NON-SURGICAL FIBROID TREATMENT........................................................................................................................12
TREATMENT OF FIBROIDS........................................................................................................................................13
LECTURES WEEK 3........................................................................................................................................ 13
A GENERAL INTRODUCTION TO SUB-/INFERTILITY........................................................................................................13
SUBFERTILITY: THE MALE FACTOR.............................................................................................................................14
OVULATION DISORDERS..........................................................................................................................................16
FUTURE PERSPECTIVES IN FERTILITY..........................................................................................................................18
ENDOMETRIOSIS...................................................................................................................................................18
TUBAL DISORDERS.................................................................................................................................................19
LECTURES WEEK 4........................................................................................................................................ 20
THE YOUNG PREGNANCY........................................................................................................................................20
GENERAL INTRODUCTION TO TREATMENT OF SHOCK....................................................................................................21
EXTRA UTERINE PREGNANCIES.................................................................................................................................21
MISCARRIAGE......................................................................................................................................................21
ANATOMY OF THE FEMALE REPRODUCTIVE ORGANS.....................................................................................................23
LECTURES WEEK 5........................................................................................................................................ 23
MULTIPLE GESTATION............................................................................................................................................23
HYPERTENSIVE DISORDERS IN PREGNANCY.................................................................................................................25
SILDENAFIL THERAPY IN DISMAL PROGNOSIS EARLY-ONSET IUGR (STRIDER)...................................................................27
SCREENING AND DIAGNOSIS OF FGR........................................................................................................................27
METABOLIC SYNDROME.........................................................................................................................................29
MANAGEMENT AND PROGNOSIS OF HYPERTENSIVE DISORDERS AND FGR........................................................................30
LECTURES WEEK 6........................................................................................................................................ 31
PERINATAL MORTALITY AND PERINATAL AUDIT.............................................................................................................31
,Summary minor challenges in women and child healthcare N. Smit - 2023
Lectures week 1
Development of the female internal reproductive organs
Pregnancy starts with the first day of the last menstrual cycle. Fertilization is about two
weeks later. Week 2 – week 10 is the embryonic period. From 10 weeks it is called the fetal
period. Fetal viability is from 24 weeks, this also makes 24 weeks the ultimate date for an
abortion.
Embryonic period
The embryonic period is counted from the moment of fertilization. A woman who is pregnant
for 8 weeks, has an embryo of 6 weeks old. After 3 weeks of embryonal development (GA 5
weeks) a three-layered germinal disc has formed consisting of the ectoderm, endoderm, and
mesoderm. The embryonic period is counted in 23 carnegie stages, because you can never
know exactly when natural fertilization took place. A pronephros has never been found in
human embryos. the embryonic period is clinically not relevant, because abnormalities are
visible with an ultrasound and thus in the fetal period.
MRKH syndrome
MRKH syndrome is characterized by a congenital absence of the uterus and the upper part of
the vagina. The etiology is mostly unknown. The reproductive abnormalities are due to
incomplete development of the Müllerian duct. This structure in the embryo develops into
the uterus, fallopian tubes, cervix, and the upper part of the vagina. The ovaries are present.
Endocrinologically FSH/LH/estrogens are normal, just as the secondary sexual
characteristics (mammae).
Diagnosis mostly in puberty due to primary amenorrhea. This is defined
as no menarche before 16 years old or 5 years after the
thelarche (breast development)
Karyotype 46XX with a normal fenotype
Hypothesis autosomal dominant inheritance with sex-limited (female)
expression and incomplete penetrance
Besides this, other abnormalities have been recorded. 30-50% of the patients have
abnormalities in their uropoetic tract, such as a renal agenesis, horseshoekidney and a pelvic
kidney. 20-40% has skeletal problems, <10% hearing problems ans <10% cardiac problems.
This is caused by the development of the skeleton, kidneys, and hearing all at the 6th week.
Type 1 MRKH typical type, 44%. Uterus and upper 2/3 part of the vagina is missing.
,Summary minor challenges in women and child healthcare N. Smit - 2023
Type 2 MRKH atypical type, 56%. Uterus, upper 2/3 part of the vagina AND ≥ 1 additional
malformation. Also known as MURCS.
The ovaries produce estrogen, the uterus has no role in the production of female hormones,
thus you can explain to a patient she ‘is still female’ with this diagnosis. Penetration is not
possible, but she can still have a clitoral orgasm.
Treatment of MRKH; neovagina/vaginal reconstruction
Non-surgical treatment
The non-surgical way to create a neovagina is with dilatation of the existing vaginal cavity.
Either with dilators or through sexual intercourse with penetration. Franks’ method is dilating
1-3 times a day for 10-30 minutes. Important to first push downwards so that the skin of the
ureter is not pulled. Requires a lot of motivation and support. In about 6 months a depth of 6
centimeters can be reached. Success rate of 90-95%. A complication is a prolaps.
Surgical treatment
Several surgical techniques to reconstruct a vagina. Most frequent used procedure is
Vechietti. This procedure creates a neovagina through continuous invagination of the vaginal
dimple by an olive-shaped vaginal dilator. The vaginal “olive” is connected to a spring-loaded
tensioning device on the patient's abdomen via laparoscopically placed sub-peritoneal
sutures. The sutures are tensioned by 1-1,5 cm each day over the course of 5 to 7 days. Quick
result, good lubrication and result of 90-94%.
Another procedure is Davydov. It is a three-stage procedure that requires dissection of space
between the urethra, bladder, and rectum, followed by peritoneal mobilization which is
subsequently sutured to the edges of the vaginal vestibulum. It also requires postoperative
dilation and is suitable for women who underwent extensive pelvic surgeries.
Mclendoe either uses a split or full thickness skin graft. This graft is wrapped around a mould
and placed in situ for 1-2 weeks. Negative aspect is the vaginal hairgrowth, this can be
reduced via lasertherapy. Less lubricated.
, Summary minor challenges in women and child healthcare N. Smit - 2023
Last technique is the sigmoid technique. Part of the sigmoid with its vascular pedicles is
removed via laparotomy and repositioned to form a vagina.
Neovaginas are not SOA proof, but there are no ascending infections possible.
Transplantation of the uterus
A uterus transplantation is possible when a person has an absolute uterine factor infertility
(AUFI). For example people with MRKH, severe congenital uterusanomalies and after a
hysterectomy. For transwomen (MF) it is not yet an option, but it might be in the future.
Alternatives for uterus transplantation in NL are high-technological surrogacy
(hoogtechnologisch draagmoederschap), adoption and fostercare.
The surgery of the donor costs about 10-13 hours, the recipients’ about 4-5 hours.
MRKH women after a uterus transplantation already had an ovulation, nothing will
change about this. Did not menstruate in the first place, but the new uterus will respond
directly on the females’ hormones and the endometrial development. The first menstruation
will take place after 1-2 months. Natural gestation is not possible, as the fallopian tubes are
not connected IVF necessarily (IVF process must be started on forehand).
Transmen as donors is not always possible if wanted, because their uterus is smaller due to
hormone suppressing on a young age. Therefor the vessel diameter is smaller, and this has to
be as big as possible for a successful transplantation.
Costs
- Adoption: 23.350 (NL)
- Surrogacy: 15.000 (NL)
- Uterus transplantation: 100.000 (NL)
The medical ethics committee has adviced to not perform uterus transplantation in the
Netherlands. Due to scarcity of available recourses, the presence of an alternative for some
patients (HTDM) and the lack of literature studies.
After two births (always a CS) the uterus is removed. Patient otherwise has to be on
immunosuppressives for the rest of their life. Maximum of two due to the scarcity of the
resources and services via IVF.
Uterine anomalies
The reproductive system is embryologically formed out of the mesonefros. The urogenital
tract develops from the mesonephric duct (Wolff), the paramesonephric duct (Muller) and
the urogenital sinus. In absence of AMH/testosterone/in XX the Wolffian duct degenerates
and the Mullerian tract develops the female reproductive tract. Uterine anomalies may form
if the fusion of the Mullerian tracts fails. Because of the embryological history, always think
of renal abnormalities in case of a uterine anomaly.
The ASRM classification is a formerly used classification system to classify the abnormalities
of the uterus and/or cervix. Later the ESHRE/SGE classification was introduced. This
describes what you see per section (uterus/cervix/vagina)
