Breaking Bad News Flashcards
What is the general framework for breaking bad news?
- Summarise where things have got to at that point
- Assess the patients understanding - what they already know / are thinking.
- Give warning that difficult information is to come. Chunk information, check repeatedly for understanding. Use language with respect to patients intelligence.
- Specifically elicit concerns, and check understanding of information given - “would you like to run through what you are going to tell your husband?)
- Be aware of unshared meanings
What is moderate dyskaryosis?
Screening is designed to find early changes that could become cancer in the future
Dyskaryosis is a medical term used to describe abnormal changes seen with cervical screening. It is not cancer; about 9 in 10 cases of dyskaryosis revert back to normal on their own, without treatment.
“Moderate” means that the cells are less likely to return to normal by themselves, and we would like to investigate them further.
Moderate dyskaryosis: What are the next steps?
Refer to colposcopy:
This gives a more detailed look at the cervix. A speculum (like used for the smear) is put into the vagina, and the doctor will use a magnifier to look at the cervix in more detail. The colposcope itself does not go inside the vagina.
The cervix is ‘painted,’ which helps to show up abnormal cells. It takes longer than a smear test; about 15 minutes. The doctor may either want to take a small chunk of cells for further analysis, or to perform a loop excision to remove abnormal areas of cells. This is a straightforward procedure, it’s done with local anaesthetic, and it very rarely has complications. However, it can predispose to prematurity.
Moderate Dyskaryosis: What are the consequences?
- Without treatment, 1 in 3 go on to develop cancer in around 10 years.
- Ablation is a straightforward operation, which is 95% successful; abnormal cells are removed and there are clear margins in the vast majority. However, the risk of invasive cancer remains higher, therefore vigilence is required.
- Increased screening: cytology at 12 and 24 months, or more often if positive margins.
What does LLETZ involve?
It is a very thin wire loop, that enables removal of a small part of the cervix (neck of the womb) where the abnormal cells are.
It is a relatively simple operation; you will be given some local anaesthetic, and will be able to go home almost immediately after it is done
After the operation, you should avoid using tampons, having sex, bathing in hot water, or engaging in heavy exercise for 3 / 4 weeks
Risks of infection, bleeding, uterine perforation, and cervial incompetence. All are small, and the risk of leaving dyskaryosis unchecked is much greater.
What are the causes of moderate dyskaryosis (offer only if asked)
- Greatest risk factor is HPV infection. This is a virus that lives in the cervix. There are over 100 different strains, of which four have a predisposition to cause cancerous change. Most infections are transient and occur in young women - persistence is a key factor in developing CIN. 50% clear within 6 - 18 months, and 80-90% resolve within 5 years.
- Immunosuppression
- Cigarette smoking: having HPV and smoking gives a 4 fold increased risk of progression to CIN compared to not smoking.
- OCP
What is a missed miscarriage?
A “missed miscarriage” occurs when the fetus has stopped developing in the womb, but has not been passed. It is not recognised until there is bleeding, or it is seen on USS.
Once you have a positive pregnancy test, there is a one in five chance of miscarriage in the first three months. Most miscarriage occur as one off events and there is a good chance of having a successful pregnancy in the future.
Why does miscarriage occur?
The most common causes is chromosome problems of the baby, and a miscarriage is body telling us that a pregnancy wasn’t meant to be. Chromosomal abnormalities occur at random; it is just chance that a particular sperm and egg fertilize that are incompatible. It does not mean it will happen again.
Many people worry that miscarriage is as a result of something they have done, such as exercise, stress, intercourse or emotional trauma. There is no scientific evidence that any of these cause miscarriage.
The risk of miscarriage can be increased by:
- Age
- Health problems such as poorly controlled diabetes
- Lifestyle factors such as smoking and heavy drinking
What are the options available for “completing” the miscarriage?
Letting nature take its course
- Successful in 50% of women. May take time before bleeding starts, and it is normal for bleeding for continue for up to three weeks.
- Bleeding may be heavier than normal, and there may be cramping pain. Very rarely, admission for heavy bleeding or severe pain may be necessary.
- If bleeding does not start, you will be offered the option of taking tablets or having an operation.
Taking tablets
- Given tablets to swallow or put into the vagina, which allow the entrance of the womb to open and pass the pregnanacy.
- Usually takes a few hours, and there is some pain with bleeding or clotting (like a heavy period). You can take pain relieving drugs. Bleeding may continue for up to three weeks.
- Successful in 85%, avoids a general anaesthetic. You only need to be in hospital for a few hours, and then you can go home. However, there is a risk of heavy bleeding, and you may need an emergency admission.
Having an operation
- Usually carried out under GA, and usually erformed within a few days of miscarriage. Has a success rate of 95%
- Surgery is advised if you are bleeding heavily and continuously / the miscarriage is infected / expectant or medical management is unsuccessful.
What is involved in an ERPC? What are the risks?
Performed under general anaesthetic; should have someone who is able to come and take you home afterwards. Takes about 15 - 30 mins. The cervix is opened, either with medcine before the operation or in the operation, and a tube inserted which removes the retained products.
Risks
- Partial removal of endometrium
- Uterine perforation (1%)
- Infection (3%)
- Anaesthetic risk
- Bleeding
- Damage to cervix
Missed miscarriage: when should I phone for help? What follow up will there be?
You will be given a 24-hour telephone number to use if you:
- Are worried about the amount of bleeding
- Are worried about the amount of pain you are in, and the pain relieving drugs aren’t helping
- You have a smelly vaginal discharge
- Get shivers or flu-like symptoms
- Are feeling faint
- Have any pain in your shoulders
Follow up:
- Making sense of what has happened can take some time. We’ll arrange for another appointment soon, so we can discuss things further.
