Gynae Procedures Flashcards
What is endometrial ablation?
- Outpatient procedure to remove or destroy endometrial layers (can prevent periods / heavy bleeding)
What are the indications for endometrial ablation?
- Menorrhagia in premenopausal or perimenopausal women with normal endometrial cavities
- Postmenopausal bleeding of unknown origin
- Anovulatory bleeding and bleeding secondary to fibroids – higher risk of failure as does not remove fibroids
- No desire for future fertility but desire to retain uterus or avoid hysterectomy
What are the complications of endometrial ablation?
- General = infection, bleeding, failure, damage to local structures (i.e. cervical os, uterus lining)
- Minor SE = cramping, nausea, frequent urination, watery discharge mixed with blood
- Rarely = pulmonary oedema due to fluid used to expand uterus being absorbed into blood stream
What device is most widely used for endometrial biopsy and why?
Pipelle
- Can be used without cervical dilatation
What are the indications for a endometrial biopsy?
- Over 55 +
- PMB (unexplained bleeding 12+ months after LMP)
- Unexplained discharge if its new, has thrombocytosis or reports haematuria
- Visible haematuria and low Hb, thrombocytosis, raised blood glucose
- Under 55 with unexplained bleeding 12+ months after LMP
What are the complications of endometrial biopsy?
- General = infection, bleeding, failure, damage to local structures
- Pipelle has poor negative predictive value
What are the indications for gynaecological laparoscopy?
- Diagnostic - pelvic pain, diagnose endometriosis, infertility (dye test for tubal patency)
- Therapeutic - sterilisation, adhesiolysis, ovarian cystectomy, salpingectomy, endometrial ablation
- Major surgery - myomectomy, hysterectomy
What are the complications of gynaecological laparoscopy?
- Infection
- Bleeding
- Failure
- Damage to local structures
- GA complications
- VTE
What different approaches are there for a hysterectomy?
- Vaginal (removed through vagina) - quickest recovery
- Laparoscopic-assisted vaginal
- Laparoscopic hysterectomy
- Midline-incision
What structures are removed in a total, radical and subtotal hysterectomy?
- Total → uterus and cervix
- Radical → removal of structures ± BSO
- Cervix, uterus, fallopian tubes and ovaries
- Subtotal → upper part of uterus removed
- Cervix not removed so smears at 6 and 18 months are needed
What are the contraindications to a vaginal hysterectomy?
- Malignancy
- Uterus 12w+ pregnancy
What are the indications to a vaginal hysterectomy?
- Menstrual disorders with uterus <12w size
- Microinvasive cervical carcinoma
- Uterovaginal prolapse
What are the indications to am abdominal hysterectomy?
- Uterine, ovarian, cervical, fallopian tube carcinoma
- Pelvic pain from chronic endometriosis or chronic PID where pelvis is frozen and vaginal impossible
- Symptomatic fibroid uterus 12w+ in size
What incision is made for an abdominal hysterectomy?
- Pfannenstiel incision
- Midline incision if larger masses or malignancy
What are the complications of a hysterectomy?
- Infection - co-amoxiclav given intra-operatively
- Bleeding
- Failure
- Damage to local structures
- GA complications
- VTE
Describe uterine artery ablation.
- May preserve fertility but may also make ovaries fail
- Embolise both uterine arteries → infarct/degenerate fibroids
- Patients need admission to deal with pain associated (opiate analgesia)
- Complications: fever, infection, fibroid expulsion, potential ovarian failure
- 33% of women require further medical, radiological or surgical treatment <5 years
- As effective as myomectomy for alleviating fibroid DUB and pressure symptoms
What is colposcopy?
A diagnostic procedure obtaining a magnified view of the cervix, the lower part of the uterus and the vagina in order to examine the transformation zone and detect malignant or premalignant changes
What are the indications for colposcopy and/or cervical punch biopsy?
- Severe or moderate dyskaryosis
- Borderline/mild dyskaryosis smear with HPV +ve test
- 3x inadequate smear
- Suspicious looking cervix
- Glandular neoplasia on smear
What are the complications of colposcopy?
- Few/No complications from colposcopy alone
- Colposcopy + excisional treatments:
- Bleeding
- Infection
- Cervical incompetence in future pregnancies
What are the complications of cervical punch biopsy?
- Rare but include:
- Excessive bleeding for 1-week
- Mild cramping
- Vaginal soreness
- Dark discharge
What is an epidural?
Regional anaesthesia performed by injecting anaesthetic into epidural space (different from a spinal).
What are the indications for an epidural?
- Pain relief during labour - stop thromboprophylaxis 24 hours before
- Anaesthesia for C-section
What are the complications of an epidural?
- Urinary retention
- Shivering
- Pruritus
- Headache (anaesthesia going to head)
- Hypotension
- Epidural haematoma
- Epidural meningitis
- Respiratory depression
- General = infection, bleeding, failure, damage to local structures
What is hysteroscopy?
Passing a small diameter telescope (flexible or rigid) through the cervix to inspect the uterine cavity
- Flexible hysteroscope - used in OPD setting with CO2 as filling medium
- Rigid instruments - use circulating fluids so can be used to visualise uterine cavity even if the woman is bleeding
