Patient have bleeding after 2 months of normal vaginal delivery. USG suggest bulky uterus.What next?

Endometrial biopsy... what do u think for dark color cells?

A 40-year nulliparous female presented with the fullness of vagina since 1 year & mass coming out of introitus since 4-5 months associated with foul-smelling discharge, She had pervaginal bleeding for 1 month. Menstrual cycles are regular. On L/E a large irregular mass about 12 cm x 10 cm was seen outside the introitus which was covered with a white membrane that bleeds on touch. On Bimanual examination: Uterus was bulky about 6 to 8 weeks GA size, Cervix moved with the movement of tumor. What should be the management procedure?

39 yr old female , endometrial curette......please note the stromal cells......

A female patient age of 23 years ago married last two years having no issue ,there was a complaint of blee since last month .now bleeding stop after takes tt ,new usg attached with post

BACTERIAL VAGINOSIS. BACTERIAL VAGINOSIS// NON SPECIFIC VAGINITIS// GARDNERELLA VAGINITIS BV is characterised by abnormal vaginal discharge which results from an overgrowth of atypical bacteria in the vagina.It is not a true injection but rather an imbalance of bacteria that are normally present in the vagina. In the past,this condition was called "Gardnerella vaginitis"after the bacteria that were thought to cause the condition.But now it is coined as "Bacterial vaginosis"due to the fact that there are a number of species of bacteria that naturally live in the vagina and imbalance of these normal resident flora of vagina leads to BV. Gardnerella vaginalis,lactobacillus,prevotella, mobiluncus,bacteroides,peptostreptococcus, fusobacterium,veillonella,eubacterium, mycoplasma hominis,ureaplasma urealyticum, streptococcus viridans &atopobium vaginae are all associated with bacterial vaginosis. SIGNS AND SYMPTOMS 1.Abnormal amounts of vaginal discharge. 2.Thin & grayish colored vaginal discharge. 3.Unpleasnt "FISHY ODOUR" 4.Discharge and odour are more noticeable after sexual intercourse. 5.Dyspareunia and dysuria rare. RISK FACTORS. 1.Recent antibiotic use. 2.Decreased estrogen production of the host. 3.Intra uterine device in situ. 4.Douching. 5.New partner or multiple partners. DIAGNOSIS. Microscopic examination is vital to the clinical diagnosis of bacterial vaginosis. Demonstration of 3 of the following 4 criteria "AMSEL CRITERIA" is essential to diagnose BV on microscopic examination of the discharge. AMSEL CRITERIA 1.Demonstration of "CLUE CELLS"on a saline smear.(The most specific diagnostic criterion) 2.A pH of >>4.5. 3.Characteristic thin,gray and homogeneous discharge. 4.Positive "WHIFF TEST" Whiff test is performed by adding a small amount of potassium hydroxide to a microscopic slide containing vaginal discharge A CHARACTERISTIC FISHY ODOUR IS CONSIDERED A POSITIVE WHIFF TEST AND IS SUGGESTIVE OF BACTERIAL VAGINOSIS. NUGENT'S CRITERIA. Bacteria are graded via gram staining of vaginal discharge sample.bacteria are graded and assigned score 1.Lactobacillus (score 0-4) 2.Bacteroides /Gardnerella (score 0-4) 3.Mobiluncus (score 0-2) Total scores are calculated and interpreted as follows. 0-3 Normal. 4-6Intermediate bacterial count. 7-10 Bacterial vaginosis. MANAGEMENT. 1.Antibiotics are the mainstay of therapy. 2.Asymptomatic women do not need treatment 3.BV in pregnant women should be treated. 4.BV should be treated before a caesarean section,hysterectomy or insertion of IUD. 5.Uncomplicated cases typically resolve after standard antibiotic treatment. 6.BV that does not resolve after one course of treatment may be given the second course of the same agent or by switching to another agent.(metronidazole to clindamycin or clindamycin to metronidazole) 7.Patients should be advised to stop douching or using bubble bath or over-the-counter vaginal hygiene products. 8. Patient should avoid soaps,liquid soaps and body washes. 9.Surgery is not indicated. 10.Testing for other infections like Neisseria gonorrhoea. Chlamydia trachomatis. Harper simplex virus (HSV-1) is appropriate. COMPLICATIONS. The prognosis for uncomplicated cases of bacterial vaginosis is excellent. Complicated cases of bacterial vaginosis lead to increased risk of. Salpingitis. Endometritis. Post caesarean endometritis. Post hysterectomy vaginal cuff cellulitis. In pregnancy Premature rupture of membranes. Premature labor. Chorioamnionitis. Post partum endometritis.