Gynaecology - Management Flashcards
POP (pelvic organ prolapse) conservative management
Who is given conservative management?
What does consversvative management consist of?
• Conservative – mild prolapse, want further pregnancies, frail/elderly, high anaesthetic risk, do not want surgery
1st line
o Watchful waiting
o Lifestyle modification – weight loss, minimising heavy lifting, smoking cessation (reduces chronic cough and therefore intra-abdominal pressure), preventing or treating constipation
2nd line
o Pelvic floor muscle exercises – with symptomatic POP-Q stage 1 or stage 2 prolapse – supervised 16-week course of pelvic muscle training
o 3-month trial (subsequent to digital assessment of pelvic muscle contraction)
o 8 contractions, 3x day, 3 months
o Vaginal oestrogen creams – for women with signs of vaginal atrophy
o An oestrogen-releasing ring – for women who have physical/cognitive problems which cause use of vaginal oestrogen pessaries or creams to be difficult
POP (pelvic organ prolapse) if conservative management (1st line) failed
Vaginal pessary insertion - 2nd line
o Good alternative to surgery
Short term relief of prolapse prior to surgery
Long term if surgery is not wanted or is contraindicated
o Alone or in combination with pelvic muscle exercises
o Inserted in the vagina to reduce the prolapse, provide support, relieve pressure on the bladder + bowel
o Made of silicone or plastic
Surgery - 3rd line o Referral Failure of conservative treatment Presence of voiding problems or obstructed defecation Recurrence of prolapse after surgery Ulceration Irreducible prolapse The woman prefers surgical treatment
o Goals
Restore anatomy
Improve symptoms
Return bowel, bladder, sexual function to normal
o Surgery may be by the abdominal route or vaginal
80-90% of procedures are done by the vaginal route
Types of vaginal pessaries available for POP (pelvic organ prolapse)
o Ring Usually first choice Common type Soft Does not prevent sex
o Shelf Common type Hard More support than a ring Prevents sex
o Gellhorn
Similar to shelf but soft instead of hard
Prevents sex
o Gehrung
Disk-shaped
Used for more serious prolapse
Easier to remove
o Cube
For very advanced prolapse
Uses suction to keep things in place
Different types of surgeries used to repair POP (pelvic organ prolapse)
Surgery for anterior (cystocele, cystourethrocele) or posterior (rectocele or enterocele) prolapse
o Surgery for anterior (cystocele, cystourethrocele) / posterior (rectocele or enterocele) prolapse
Anterior/posterior colporrhaphy without mesh
Recommendations related to the use of synthetic polypropylene or biological mesh insertion have been withdrawn – serious but well-recognised safety concerns
o Surgery for bladder/urethral prolapse [not on NICE]
Anterior colporrhaphy = Anterior vaginal vault repair
• Central plication of the fibromuscular layer of the anterior vaginal wall
• Performed transvaginally
Colposuspension
• Open or laparoscopic
• Urethral sphincter incontinence associated with cystourethrocele
• Corrects SUI + cystocele
• Can worsen rectocele
• Low transverse suprapubic incision
• Elevates bladder neck and base
• SE of surgery – any paravaginal plexus damage can lead to lots of bleeding, voiding difficulties short term, de novo urgency, worsens rectocele
• Colposuspension performed at the time of sacrocolpopexy – to reduce postoperative symptomatic SUI in previously continent women
o Surgery for rectocele/enterocele [not on NICE]
Posterior colporrhaphy = posterior vaginal wall repair
• Levator ani muscle plication or by repair of discrete fascial defects
• Transvaginal approach more effective than transanal repairs
Different types of surgeries used to repair POP (pelvic organ prolapse)
Surgery for uterine prolapse
o Surgery of uterine prolapse
Hysterectomy (+/- vaginal sacrospinous fixation with sutures)
• Removal of the uterus +/- stitching the top of the vagina to the sacrospinous ligament
• No abdominal incision needed - less pain + hospital stay
• Can be combined with anterior/posterior colporrhaphy
Sacrohysteropexy with mesh
• Uterus is attached to the anterior longitudinal ligament over the sacrum using a mesh
• Open abdominal or laparoscopic
• If woman wishes to retain her uterus
Vaginal sacrospinous hysteropexy
• Unilateral/bilateral fixation of the uterus to the sacrospinous ligament
• Performed via vaginal route
• If woman wishes to retain her uterus
Manchester repair
• Shortening of the cervix + supporting the uterus in its natural position
• If woman wishes to retain her uterus but is not planning on having children in the future
Colpocleisis
• Obliterative surgery
• Can be used for vault or uterine prolapse
• Corrects prolapse by moving the pelvic viscera back into the pelvis + closing off the vaginal canal
• Vaginal intercourse is no longer possible
• 100% effective in treating prolapse, reduced peri-operative mortality
• Safe + effective for those who are frail or do not with to retain sexual function or are at an increased risk of operative and postoperative complications
Different types of surgeries used to repair POP (pelvic organ prolapse)
Surgery for vaginal vault prolapse
o Surgery for vaginal vault prolapse
Sacrocolpopexy with mesh [1st line]
• Mesh used to attach the vagina to the sacral vertebrae
• Mesh may be attached at one end to the longitudinal ligament of the sacrum and at the other to the top of the vagina and for a variable distance down the posterior and/or anterior vaginal walls
• Open abdominal, laparoscopic, robotic
• Most effective procedure – low recurrence rate
Vaginal sacrospinous fixation
• The top of the vagina is stitched to the sacrospinous ligament
Colpocleisis
• Obliterative surgery
• Can be used for vault or uterine prolapse
• Corrects prolapse by moving the pelvic viscera back into the pelvis + closing off the vaginal canal
• Vaginal intercourse is no longer possible
• 100% effective in treating prolapse, reduced peri-operative mortality
• Safe + effective for those who are frail or do not with to retain sexual function or are at an increased risk of operative and postoperative complications
Different types of surgeries used to repair POP (pelvic organ prolapse)
Surgery for women with both stress urinary incontinence + pelvic organ prolapse
Colposuspension • Urethral sphincter incontinence associated with cystourethrocele • Open or laparoscopic • Corrects SUI + cystocele • Can worsen rectocele
Consider concurrent surgery for stress urinary incontinence and pelvic organ prolapse in women with anterior and/or apical prolapse and stress urinary incontinence
o Review 6 months after surgery [vaginal examination, mesh exposure]
Vaginal pessary for POP (pelvic organ prolapse) complications
o Vaginal discharge and odour o Vesicovaginal + rectovaginal fistulas o Faecal impaction o Hydronephrosis o Urosepsis o Pessary may have an effect on sexual intercourse o Bleeding o Difficulty removing pessary o Expulsion
POP (pelvic organ prolapse) complications
• Prolapse
o Ulceration + infection of organs prolapsed outside the vaginal introitus
o Urinary tract complications – stress incontinence, chronic retention, overflow incontinence, recurrent UTI
o Rectocele – bowel dysfunction
POP (pelvic organ prolapse) complications of surgical management
• Apical/anterior prolapse surgery – postoperative urinary incontinence
• Sacrospinous Hysteropexy
o Lower success rate than sacrohysteropexy
o Risk of injury to the pudental nerve and vessels and the sciatic nerve
o Faster recovery and higher patient satisfaction
- Anterior colporrhaphy – haemorrhage, haematoma, cystotomy
- Posterior colporrhaphy – levator plication may lead to dyspareunia
• Mesh surgery
o Vaginal mesh extrusion and erosion – vaginal bleeding, pelvic pain, dyspareunia
o Pain or sensory change in the back, abdomen, vagina, pelvis, leg, groin, perinium that is
Unprovoked or provoked by movement or sexual activity
Either generalised or in the distribution of a specific nerve e.g. obturator nerve
o Vaginal discharge, bleeding, dyspareunia, penile trauma, pain
o Urinary problems – recurrent infection, incontinence, retention, difficulty/pain during voiding
o Bowel problems – difficulty/pain on defaecation, faecal incontinence, rectal bleeding, passage of mucus
o Symptoms of infection
USI urinary stress incontinence management
• ?UTI
o UTI sx + positive urine tests for leukocytes + nitrites – send urine MSU, start antibiotic treatment while waiting for results
o UTI sx + negative urine tests for leukocytes + nitrites – send urine MSU, consider starting antibiotic treatment while waiting for results
o No UTI sx + positive urine tests for leukocytes + nitrites – send urine MSU, do not start antibiotic treatment until you have the results
• Temporary containment products to achieve social continence offered until there is a specific dx and management plan – pads, collecting devices
STRESS INCONTINENCE
• Lifestyle changes, avoid caffeinated drinks, weight loss (only if BMI >30), smoking cessation, avoid drinking either excessive/reduced amounts of fluids daily, pelvic floor exercises, treat constipation
• Bladder diary for a min of 3 days
• Pelvic floor muscle exercises – 1st line
o 3-month trial (subsequent to digital assessment of pelvic muscle contraction)
o 8 contractions, 3x day, 3 months
o Continue if successful
o Consider electrical simulation +/or biofeedback in women who cannot actively contract pelvic floor muscles to aid motivation and adherence to therapy
o Patient information leaflet, can refer to physiotherapist
- Surgery – 2nd line
- If non-surgical management for stress incontinence has failed and the woman wishes to think about a surgical procedure – colposuspesion or autologous rectus fascial sling
o Colposuspension
Open or laparoscopic
Corrects SUI + cystocele
Can worsen rectocele
Neck of the bladder is lifted up and stitched in place to Cooper’s ligaments/Pectineal ligament
SE of surgery – any paravaginal plexus damage can lead to lots of bleeding, voiding difficulties short term, de novo urgency, worsens rectocele
Colposuspension performed at the time of sacrocolpopexy – to reduce postoperative symptomatic SUI in previously continent women
o Autologous rectus fascial sling
A sling placed around the neck of the bladder – elevates the urethra
o Intramural bulking agents
Glutaraldehyde cross-linked collagen, silicone, carbon-coated zirconium beads, hyaluronic acid
Injected to the wall of the urethra, helps it to remain closed
Considered if conservative management has failed
Their efficacy reduces with time, repeat injections may be needed
Not as effective as retropubic suspension/sling procedures
• Medication
o Duloxetine – 3rd line
SNRI, Enhances sphincter contraction
Do not routinely offer duloxetine as a second-line treatment for women with stress urinary incontinence
80% SE - dizziness, nausea
Offer it as a second line if women prefer pharmacological to surgical treatment or do not want/are unsuitable for surgery
Third line but first line if patient prefers pharmacological to surgical rx/doesn’t find pelvic floor muscle exercises effective + patient prefers pharmacological to surgical treatment/patient is not suitable for surgical treatment
Review in 2-4 weeks
o Desmopressin
To reduce nocturia if pt finds it a troublesome symptom
ADH analogue
Used in caution in women with – CF, reduced renal function, CVD
Contra-indicated in cardiac insufficiency, conditions requiring treatments with diuretics
Not oxytocin, not terbutaline
• Other interventions
o ((((Artificial sphincter
Only if previous surgery has failed
Procedure may be considered first-line in neurological disease if another procedure e.g. sling is considered less likely to promote continence
o Transvaginal laser therapy for stress urinary incontinence
Only used in the context of research
o Retropubic mid-urethral mesh sling procedure – elevates the urethra
This surgical intervention is not currently being used
Tension free vaginal tape (TVT) vs Transobturator tape (TOT)
TVT - Mesh (type 1 macroporous polypropylene tape)
Inserted transvaginally with 2 suprapubic exit points
Complications: short term voiding difficulties, de-novo urgency, Mesh erosion
Cure rate 80%
o Bladder catheterisation (intermittent/indwelling urethral/suprapubic) – should be considered for women in whom persistent urinary retention is causing
Incontinence
Symptomatic infections
Renal dysfunction
And in whom this cannot be otherwise corrected))))
MIXED INCONTINENCE – direct treatment towards the predominant symptom
OVERFLOW INCONTINENCE – refer to specialist urogynaecologist, timed voiding (1st line)
OAB (overactive bladder syndrome) urge incontinence 1st, 2nd and 3rd line management mx
• Lifestyle interventions – 1st line
o Caffeine reduction
o Pt should aim to drink normal quantities of fluid per day (about 2 litres)
If reduced – urine concentrated – irritated bladder – more detrusor muscle contractions
o Weight loss if BMI >30
o Avoid fizzy drinks, control diabetes well
• Bladder retraining – 1st line
o Min. of 6 weeks
o Progressively hold off going to the toilet (up to 25 minutes)
o Void 1.5-2L a day
o Input 1.5L/24 hours
o Aim to gradually increase the intervals between voiding
o Involves: pelvic muscle training, scheduled voiding intervals with stepped increases, suppression of urge with distraction or relaxation techniques
• Medications
o Anticholinergic drug – 2nd line
Oxybutynin, propiverine, tolterodine, darifenacin, solifenacin, fesoterodine, trospium chloride
Have a direct relaxant effect on the urinary smooth muscle + reduce involuntary detrusor contractions + increase bladder capacity
Reduces the activity of the detrusor muscle by blocking Ach to the nerves
- NICE recommends – oxybutynin (immediate release), tolterodine (immediate release), darifenacin (once daily preparation)
- Oxybutynin – 1st line (avoided in the elderly), not for >80s (official cut off)
• Darifenacin = M3 receptor agonist
• If immediate-release oxybutynin is not well-tolerated – darifenacin, solifenacin, tolterodine, propiverine, trospium or an extended release or transdermal formulation of oxybutynin should be considered as alternatives
May be used in conjunction with bladder training
Secondary care referral considered for patients who fail to respond to drug treatment after 3 months or who do not wish for drug treatment
o Mirabegron – 3rd line
Agonist of β3 receptors in detrusor smooth muscle
Promotes detrusor relaxation
Recommended only for people in whom antimuscarinic drugs are contra-indicated or clinically ineffective or have unacceptable side effects (older, frail women)
o Desmopressin
To reduce nocturia if pt finds it a troublesome symptom
ADH analogue
o Transdermal overactive bladder treatment to women unable to tolerate oral meds
o Intravaginal oestrogens to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy
SE of medications used in OAB (overactive bladder syndrome)
Oxybutynin
Darifenacin
Desmopressin
- Oxybutynin – 1st line (avoided in the elderly), not for >80s (official cut off)
- Tolterodine > oral immediate-release oxybutynin - reduced risk of dry mouth
- Extended-release preparations of oxybutynin or tolterodine might be preferred to immediate-release preparations – less risk of dry mouth
- Oxybutynin = increased risk of falls, avoided in the elderly as it may adversely affect cognitive performance (causes memory loss)
• NICE recommends – oxybutynin (immediate release), tolterodine (immediate release), darifenacin (once daily preparation)
• Darifenacin = M3 receptor agonist
Do not use in frail elderly women – can cause memory problems
Do not give if patient has closed angle glaucoma
SE: headache, memory problems, constipation, dry mouth, urinary retention, confusion
Review four-weekly, annually if stable, six-monthly if >75
o Desmopressin
Used in caution in women with – CF, reduced renal function, CVD
Contra-indicated in cardiac insufficiency, conditions requiring treatments with diuretics
Side effects: constipation, dry mouth, blurred vision, drowsiness
Link to Alzheimers over 65
OAB (overactive bladder syndrome) 4th line/secondary care management mx
• Secondary care management/ Surgical - 4th line
o For women with overactive bladder that has not responded to non-surgical mx or tx w med and who wish to discuss further treatment options
o Offer urodynamic ix to determine whether detrusor overactivity is causing her overactive bladder symptoms*
BOTULINUM TOXIN TYPE A
o First-line invasive option
o May be used if there is idiopathic OAB that has not responded to conservative treatment
Bladder wall injection with botulinum toxin type A
o only if the woman is willing, in the event of developing significant voiding dysfunction
To perform clean intermittent catheterisation on a regular basis for as long as needed or
To accept a temporary indwelling catheter if she is unable to perform clean intermittent catheterisation
o Risk of urinary retention and recurrent UTIs (need for ISC)
o 100-200 units
o 6 months
o Do not offer botulinum toxin type B
PRECUTANEOUS SACRAL NERVE STIMULATION
o If they have not responded to botulinum toxin type A or
o If they are not prepared to accept the risks of needing catheterisation associated with botulinum toxin type A
o 12 sessions weekly (30 mins)
PRECUTANEOUS POSTERIOR TIBIAL NERVE STIMULATION (PTNS)
o Should be offered to patients who do not want the first or second line options
o SURGICAL TREATMENT
o Only indicated for intractable and severe idiopathic OAB
o Augmentation cystoplasty is the most frequently performed surgical procedure for severe urge incontinence
AUGMENTATION CYSTOPLASTY
o Open or laparoscopic
o Restrict it for the mx of idiopathic detrusor overactivity to women
Whose condition has not responded to non-surgical management and
Who are willing and able to self-catheterise
o The bladder is made larger by adding a piece of tissue from the intestines to the bladder wall (25 cm ileum to replace dissected bladder)
o Laparoscopy – less intraoperative blood loss, quicker recovery, less pain, shorter stay in hospital, smaller scars
o Complications – bowel disturbance, metabolic acidosis, mucus production and/or retention in the bladder, UTI and urinary retention, small risk of malignancy (adenocarcinoma)
o Side effects: incomplete voiding, straining, self catheterisation
o 5% adenocarcinoma
URINARY DIVERSION
o Ileal conduit
o Intra-abdominal stoma
o Causes urine to flow through an opening in the abdomen into an external bag instead of into the bladder
o Should be considered for a woman with overactive bladder only when non-surgical management has failed + if botulinum toxin type A, percutaneous sacral nerve stimulation and augmentation cystoplasty are not appropriate/acceptable to her
(((OTHER MANAGEMENT
o Bladder catheterisation (intermittent/indwelling urethral/suprapubic) – should be considered for women in whom persistent urinary retention is causing
Incontinence
Symptomatic infections
Renal dysfunction
And in whom this cannot be otherwise corrected)))
Initial management of PID (pelvic inflammatory disease)
• Start Abx before swabs if you suspect PID
o Do not delay abx while waiting for the results
o Broad-spectrum abx treatment to cover C. trachomatis, N. gonorrhoea, anaerobic infection is recommended
- Pregnant women with PID should be admitted
- Mild-moderate – can be managed in primary care
- Clinically severe – hospital admission for IV abx
• ?removal of IUCD
o May be associated with better short-term clinical outcomes
o This decision needs to be balanced against the risk of pregnancy in those who have had otherwise unprotected intercourse in the preceding seven days
BASHH guidelines for the management of PID (pelvic inflammatory disease) - outpatient
outpatient • First line (all 3) o IM ceftriaxone 1g single dose and o Doxycycline 100mg PO BD 14 days and o Metronidazole 400mg BD 14 days
• Other – STI screening, contact tracing, discuss contraception, removal if IUCD, avoid sex
• Second line (for 14 days)
o Ofloxacin 400mg BD + metronidazole 400mg PO BD or
o Moxifloxacin 400mg PO OD
• Outpatient – alternative regimens
o IM Ceftriaxone 1g stat followed by
o Azithromycin 1 g/week for 2/52
- Metronidazole – for anaerobic bacteria implicate in severe PID, may be discontinued in pt w mild/moderate PID
- Ofloxacin + moxifloxacin – avoided in pt at high risk of gonococcal PID (pt partner has gonorrhoea, clinically severe disease, following sexual contact abroad) because of high levels of quinolone resistance
- Levofloxacin 500mg OD for 14 days as an alternative to ofloxacin 400mg BD
• Ofloxain, levofloxacin, moxifloxacin o Quinolones o Effective for C. trachomatis o Not licensed for use in patients <18 o SE – tendons, muscle, joints SE o Only recommended as second line therapy except for treatment of M. genitalium-associated PID
BASHH guidelines for the management of PID (pelvic inflammatory disease) - inpatient
Inpatient – if pyrexial (>38) or septic
• Inpatient
o IV ceftriaxone 2g OD + IV doxycycline 100mg BD
followed by
o PO Doxycycline 100mg BD + PO Metronidazole 400mg BD for a total of 14 days
Or
o IV Clindamycin 900mg TID + IV gentamicin (2mg/kg loading dose) followed by 1.5mg/kg TID or a single daily dose of 7mg/kg
followed by
o PO clindamycin 450mg QID or PO doxycycline 100mg BD to complete 14 days + PO metronidazole 400mg BD to complete 14 days
- IV therapy should be continued until 24h after clinical improvement, then switched to oral
- Other – STI screening, contact tracing, discuss contraception, removal if IUCD, avoid sex
Bartholin’s cyst management
Conservative management
• Cyst – nothing
• Abscess
o Incision + drainage
o Broad spectrum abx (co-amoxiclav) to treat smaller abscesses until cultures are obtained
o Flucloxacillin OD is often prescribed
• Warm baths to encourage spontaneous rupture and symptomatic relief
Marsupialisation
• Forming an open pouch to stop the cyst from reforming
• LA
• Vertical elliptical incision made just inside/outside the hymenal ring
• Oval wedge of skin from vulva + cyst wall is removed
• Loculations broken down with gloved finger
• Cyst wall sewn to the adjacent skin using interrupted sutures
• Large cyst – pack with ribbon gauze in flavine
• Complications after marsupialisation – haematoma, dyspareunia, infection
Word Catheter
• Balloon catheter
o LA, stab the cyst 1-1.5 cm deep
o Instrument used to break up loculations, drain cyst, pass word catheter into it (small rubber catheter with an inflatable tip)
o Inflate balloon with water or lubricating gel, pass other end in the vagina
o Leave catheter in situ for up to 4 weeks for complete epithelisation of the new tract
o Catheter removed by deflating the balloon
• Complications after balloon catheter – infection, abscess recurrence, bleeding, pain, scarring, expulsion of the bulb of the catheter, dyspareunia
Other techniques (less popular)
• Incision + curettage of the cavity
• Application of sliver nitrate to the abscess cavity
• Insertion of a plastic (Jacobi) ring
• Use of CO2 laser
• Complete excision of gland avoided unless malignancy is suspected
Endometriosis medical management
analgesia for all according to the WHO pain ladder
Medical management – should be avoided for women who are trying to conceive
• Pain – Paracetamol +/- NSAID - 1st line
o Adjunct – tranexamic acid
• For laparoscopically confirmed case – Suppression of ovarian function for at least 6 months
o COCP
o Levonorgestrel intrauterine system
o Oral depot Medroxyprogesterone acetate
o Danazol
o GnRH agonist (e.g. leuprorelin)
Tx given for 3 months may be as effective as tx given for 6 months in relieving endometriosis-associated pain
Do not use longer than 6 months – inhibits oestrogen release – osteoporosis risk
Menopause-like side effects (hot flushes, night sweats)
If longer/repeated treatment required – GnRH can be extended with “add-back” therapy:
Low dose oestrogen/progestogen/tibolone to relieve menopausal SE + prevent bone loss
Can be used as an adjunct to surgery for deep endometriosis involving bowel/bladder/ureter (planned surgery)
• Laparoscopy may not be need if there is no evidence of pelvic mass on examination therapeutic trial of:
o COPC (monthly or tricycling)
Monthly – Take 21 days with 7 days off
Tricycle – take 3 packs, back to back
o Progestogen
To induce amenorrhoea in those where COPC is contraindicated
- Rectovaginal endometriosis refractory to other medical/surgical treatment aromatase inhibitors + COCP/GnRH analogues
- Medical treatment of symptomatic extragenital endometriosis – if surgical removal/excision not possible
- In infertile women with endometriosis clinicians should nor prescribe hormonal treatment for suppression of ovarian function to improve fertility
Endometriosis surgical management
• Pain – Paracetamol +/- NSAID
o Adjunct – tranexamic acid
Surgical management
• Laparoscopic excision at the time of dx laparoscopy
• Planned laparoscopic surgery
o Removal of severely and deeply infiltrating lesions
o Ablation of endometrioid lesions
Excision > ablation
Laparoscopic surgery (planned surgery) has been shown to reduce pelvic pain when compared to diagnostic laparoscopy alone (during diagnostic laparoscopy)
Before laparoscopic surgery use GnRH analogues to shrink endometriosis (planned surgery)
After laparoscopic excision or ablation of endometriosis consider hormonal tx to prolong the benefits of surgery and mx sx
For deep endometriosis involving bowel/bladder/ureters pelvic MRI before operative laparoscopy
May also consider surgical removal or symptomatic extragenital endometriosis – if this is not possible medical treatment
o Can use oxidised regenerated cellulose during operative laparoscopy for endometriosis prevents adhesion formation
• Adhesiolysis
• Ovarian cystectomy – for endometriomas
o If >30mm in diameter – obtain histology to identify endometriosis and exclude rare cases of malignancy
o Cystectomy > drainage + coagulation, CO2 laser vaporisation
o Hormonal contraceptives for the secondary prevention of endometrioma
• Bilateral oophorectomy – often with a hysterectomy
o Hysterectomy with salpingo-oophorectomy reserved for women as a last resort
o Excise all visible endometriotic lesions at time of hysterectomy
o Hysterectomy indicated
In women who have completed their family and failed to respond to more conservative treatment
If the woman has adenomyosis or heavy menstrual bleeding that has not responded to other treatments
o Women should be informed that hysterectomy will not necessarily cure the symptoms or the disease
Endometriosis management in a woman who is trying to conceive (fertility is a priority)
• Pain – Paracetamol +/- NSAID
o Adjunct – tranexamic acid
• In women trying to conceive – no medical/hormonal management
• Endometriosis not involving bowel/bladder/ureter
o Excision or ablation of endometriosis + adhesiolysis (during diagnostic laparoscopy)
o Improves the chances of spontaneous pregnancy
• Deep endometriosis involving bowel/bladder/ureter
o Laparoscopic surgery (planned surgery)
o Pelvic MRI before operative laparoscopy
• Endometriomas
o Laparoscopic ovarian cystectomy with excision of the cyst wall
o Improves the chance of spontaneous pregnancy
o Reduces recurrence
• IVF
• Minimal-mild endometriosis
o Suppression of ovarian function to improve fertility is not effective
o Ablation of endometroid lesions + adhesiolysis is effective compared to diagnostic laparoscopy alone
o Subfertility related to minimal-mild endometriosis
Laparoscopic ablation +/- endometrioma cystectomy
No hormonal treatment if trying to conceive
Laparoscopic surgery to treat subfertility, may improve future fertility
Endometriosis management in a woman who is not trying to conceive (fertility is not a priority)
• Pain – Paracetamol +/- NSAID
o Adjunct – tranexamic acid
• Peritoneal endometriosis not involving bowel/bladder/ureter or uncomplicated ovarian endometriomas
o Laparoscopic excision or ablation (during diagnostic laparoscopy)
o Hormonal treatment after laparoscopic excision or ablation
• Deep endometriosis involving bowel/bladder/ureter
o 3-month course of GnRH before laparoscopic surgery – to shrink endometriosis
o Pelvic MRI before operative laparoscopy
o Laparoscopic surgery (planned surgery)
• Endometriomas
o Excision rather than ablation
• Hysterectomy with BSO (bilateral salpingo-oophorectomy)
Initial management of endometriosis
Initial management (1st line)
• Pain – Paracetamol +/- NSAID (3months)
o Adjunct – tranexamic acid
• Hormonal treatment – COPC or progesterone (POP, implant, injectables, LNG-IUS) (3 months)
Medical management of fibroids
• Only required if symptomatic (fibroids >3cm)
• Uterine fibroids
o Single most common indication for hysterectomy
Pharmacological
1st line non-hormonal (not contraceptive)
• Antifibrinolytic agents (e.g. tranexamic acid)
o Tranexamic acid 1g TDS (contraindications: renal impairment, thrombotic disease)
• NSAIDs (e.g. ibuprofen, mefenamic acid)
o decrease menstrual blood loss when the cause is unknown
o Contraindications – IBD
1st line hormonal (contraceptive)
• COCP
• Cyclical oral progestogens
• LNG-IUS (Mirena)
o More effective than COCP
o decrease amount of menstrual loss
o decrease uterine size in women with fibroids
• GnRH agonist
o decrease size of fibroids during treatment but once discontinued fibroid size increases again
o Used pre-hysterectomy
o Associated with significant side effects – menopausal symptoms (hot flushes, sweating, vaginal dryness), bone loss, osteoporosis
• Ulipristal acetate
o SPRM (selective progesterone receptor modulator) with predominantly inhibitory action
o Shrinks fibroids, reduced bleeding – Inhibits cell proliferation inducing apoptosis
o Should only be used for intermittent treatment of moderate to severe uterine fibroid symptoms before menopause and when surgical procedures (including uterine fibroid embolisation) are not suitable or have failed
o Reports of serious liver injury
Perform LFTs at least once monthly
Stop treatment if transaminase levels are >2 x the upper limit of normal
Repeat LFTs 2 and 4 weeks after stopping treatment
Surgical management of fibroids
Indications + types of surgery
Surgical
Indicated when
• There is excessively enlarged uterine size
• Pressure symptoms are present
• Medical management is not sufficient to control symptoms
• The fibroid is submucous and fertility is reduced
• Myomecotmy
o Safe alternative to hysterectomy
o Open or laparoscopic
o Power morcellation used to shrink the fibroids for removal
o Maintains reproductive potential/keeps uterus
o Laparoscopic myomectomy – subserous fibroids
o Hysteroscopic myomectomy – submucosal fibroids
• Vaginal removal of pendunculated vaginal fibroids – if >60, histology to exclude sarcoma
• Hysteroscopic TCRF (transcervical removal of fibroids)
o Small submucosal or polypoid fibroids
• Hysteroscopic endometrial ablation
o Women presenting with menorrhagia
• Total hysterectomy
o In women who have completed their family – hysterectomy remains the most effective treatment for excessive uterine bleeding
o In women with many fibroids
o Small fibroids – vaginal route
o Large fibroids, intraligamentous fibroids – laparotomy with preservation of ovaries
o Laparoscopic hysterectomy – higher risk of urinary tract injury + severe bleeding in comparison to open surgery
o Risk of blood loss directly related to uterine size – reduced by pre-treatment with GnRH agonists
• Uterine artery embolization (UAE)
o Effective and safe for women who wish to keep their uterus
o May preserve fertility, may also make ovaries fail
o Embolise both uterine arteries – infarct/degenerate fibroids
o Patients need admission to deal with associate pain (opiate analgesia)
• MRI-guided transcutaneous focused US
o Low morbidity, rapid recovery
o High-power US are used to ablate the fibroid – there may be skin burns as a result
Risks of different surgical approaches in the management of fibroids
Myomectomy
Uterine artery embolization
Myomectomy
o Risk of
Excessive bleeding – cross match blood
Requiring hysterectomy at the time of operation –obtain consent for hysterectomy
C-section in the future – risk of uterine rupture
Uterine artery embolization
o Risk of
Fever, infection, fibroid expulsion, potential ovarian failure
Placental insufficiency – small-for-gestational-age babies, increased c-section, prematurity
May necessitate hysterectomy due to complications during procedure – consent beforehand
o As effective as myomectomy for alleviating fibroid DUB and pressure symptoms
Cervical polyps management
• Management – reassurance
o Generally advised to remove (twist off if small or surgery)
o Polypectomy for symptomatic and large (>3cm) endocervical polyps
o To destroy the base of the polyp – liquid nitrogen, electrocautery ablation, laser surgery
o For more persistent lesions – surgical dilatation and curettage, electrosurgical excision, hysteroscopic polypectomy
o Send for histology
Cervical ectropion management
Reassurance
Cauterisation - burn + remove
Cryotherapy - freeze + remove
Move from oestrogen-based contraceptives
Endometrial polyp managment
o May resolve spontaneously if small
o Premenopausal – polypectomy for polyps >1.5 cm/symptomatic polyps/prolapsed polyps/multiple polyps/polyps associated with infertility
o Postmenopausal – polypectomy or hysterectomy
o Hysteroscopic removal or morcellation
o Polypectomy to (day case under GA or OPD under LA)
Alleviate AUB (abnormal uterine bleeding) symptoms
Optimise fertility
Exclude hyperplasia/cancer
First line management of menopause
Healthy lifestyle – 1st line
• Smoking cessation, lose weight, limit alcohol + caffeine, regular aerobic exercise
• Adequate calcium intake (around 700 mg/day)
• Hot flushes – regular exercise, WL, reduce stress
• Sleep disturbance – sleep hygiene, no late evening exercise
o Mood – sleep hygiene, regular exercise, relaxation techniques
o Cognitive symptoms – sleep hygiene, regular exercise
First line management of menopause
Oestrogen (Elleste Solo) to women without a uterus
• OD, oral oestrogen – standard therapy
Oestrogen + progestogen (Elleste duet) to women with a uterus
• Progesterone protects the endometrium
• You can have an oestrogen only preparation combined with an LNG-IUS (Mirena coil, releases progesterone)
o Progesterone – oral progesterone, mirena (better at protecting uterus)
o Topical oestrogen – vagifem, ovestin
o oestrogen patches
Pattern of HRT in peri-menopausal and post-menopausal women
Pattern of HRT
• Peri menopausal - Cyclical/Sequential pattern (SCT)
o Monthly:
Oestrogen every day of the month + progesterone the last 14 days
Produces a bleed every month
Indication – Regular periods + menopause symptoms
o 3-monthly
Oestrogen every day + progesterone alongside if for around 14 days every 3 months
Indication – irregular periods + menopause symptoms
Produces a bleed every 3 months
Common cause of IMB = endometrial polyp
• Post-menopausal (no period for >1 year) - Continuous pattern (CCT)
o Oestrogen + progesterone every day
SE of HRT
- Oestrogenic – breast tenderness, nausea, headaches
- Progestogenic – fluid retention, mood swings, depression
• Unscheduled vaginal bleeding
o Common in the first 3 months of HRT
o Sequential>continuous HRT
o Investigate if it continues
past 6 months or
after a spell of amenorrhoea)
Contraindications to HRT
- Any oestrogen-sensitive cancer
- Current or past Breast cancer
- Untreated endometrial hyperplasia
- Undiagnosed vaginal bleeding
- Hx of VTE
- Current thrombophilia (AT-III, FV Leiden)
- Severe liver disease
- Pregnancy
Benefits of HRT
• Improved menopause symptoms - Most effective treatment to relieve the symptoms caused by menopause completely, particularly
o Vasomotor symptoms (hot flushes/night sweats)
o Mood swings
o Vaginal + bladder symptoms
• Osteoporosis
o Risk of fragility fracture is decreased while taking HRT
Fragility fracture – fracturs that result from mechanical forces that would not ordinarily result in fracture (fall from a standing height or less)
Most commonly occur in the spine, hip, wrist
Reduced BMD is a major RF
o This benefit is maintained during treatment but decreases once treatment stops
o This benefit may continue for longer in women who take HRT for longer
• Cardiovascular disease
o Oral (but not transdermal) oestrogen associated with a small increase in the risk of stroke
o HRT oestrogen alone associated with no/reduced risk of CHD
o HRT oestrogen + progestogen associated with no/little increase in the risk of CHD
Risks of HRT
• Cancer
o Oestrogen only – endometrial cancer, ovarian
o Combined – breast cancer, ovarian
o Any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT
• VTE
o Risk increased by oral HRT (oral>transdermal)
o Risk of VTE associated with transdermal no greater than baseline population risk
o Consider transdermal HRT for menopausal women who are at increased risk of VTE, incl. those with BMI >30kg/m2
Managing short-term menopausal symptoms
- Vasomotor symptoms
- Psychological symptoms
- Altered sexual function
- Urogenital atrophy
- Vaginal dryness
- Osteoporosis
- Herbal or complementary treatments
Managing short-term menopausal symptoms and alternative therapies to HRT
• The recommendations in this section are not intended for women with premature ovarian insufficiency (POI)
• Vasomotor symptoms
o HRT
o Do not routinely offer SSRI or SNRI or clonidine as first-line treatment for vasomotor symptoms alone unless HRT cannot be given
o SSRIs – fluoxetine, paroxetine, sertraline, citalopram
Paroxetine is the most effective
Women on tamoxifen should not take fluoxetine or paroxetine makes tamoxifen ineffective
o SSRI-SNRIs – venlaflaxine
Velnaflaxine preferred in people taking Tamoxifen
Improvement in fatigue, mental health, sleep disturbance
o SSRI + SNRI SE – dry mouth, nausea, constipation, appetite problems, reduction in libido
o Alpha agonists – clonidine
Licenced but there are lots of anti-Ach SE
Only non-hormonal drug licensed for use for hot flushes in the UK
25 mcg BD for 2/52, increased to a max of 50 mcg TDS
Must be withdrawn gradually – suddenly stopping it can cause rebound high blood pressure
Anti-hypertensive – therefore not suitable for patients with low BP
o Gabapentin
Improves flushes and sweats
SE – sleepiness, dizziness, weight gain, dry mouth
o Vasomotor symptoms – isoflavines, black cohoshm clonidine, evening primrose oil, black cohosh, magnesium, st johns wort, acupuncture
Multiple preparations are available and their safety is uncertain
Different preparations may vary
Do not know which doses are effective
Interactions with other medicines have been reported
Not recommended for breast cancer survivors
Women on tamoxifen should not take St. John’s wort makes tamoxifen ineffectieve
• Psychological symptoms
o HRT – low mood
o CBT – low mood + anxiety
o No clear evidence for SSRIs or SNRIs
• Altered sexual function
o Testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective
o Tibolone
• Urogenital atrophy
o Vaginal oestrogen (also offered to those on systemic HRT)
o Moisturisers and lubricants can be used alone or in addition to vaginal oestrogen
o Vaginal lubricants Effective to use as non-hormone alternatives esp. if the main symptoms are pain on intercourse due to dryness
o Topical HRT in the short-term treatment of menopausal atrophic vaginitis
- Vaginal dryness – lubricants
- Osteoporosis treatment – tibolone, bisphosphonates (alendronic acid, ibandronic acid, risedroni acid, zoledronic acid), calcium, vitamin D, raloxifene (approved for prevention and treatment of osteoporosis in postmenopausal women and to reduce risk of invasive breast cancer in postmenopausal women at high risk or with osteoporosis)
• Herbal or complementary treatments
o Phyto-oestrogens
Naturally occurring compounds found in plant sources
Structurally related to estradiol
Isoflavins, genistein, daidzein, glycitein, ligans, coumestans
Soy beans, nuts, wholegrain cereals, oilseeds
Can be taken in the form of tablets
Efficacy has not been proven in RCTs, meta-analysis has shown that their use is associated with a reduction in the frequency of hot flushes
Early menopause management
Early menopause management
• HRT continued until they reach 51 years unless contra-indicated
• May need larger doses of HRT to control vasomotor symptoms
o Symptoms may be more severe in premature menopause, particularly after surgical menopause, often requiring higher doses of oestrogen than those needed following spontaneous menopause at a later age
• There is no evidence that there is any increased risk of breast cancer compared with normally menstruating women of the same age for early menopausal women on HRT
Premature ovarian insufficiency POI management
Premature ovarian insufficiency POI management
• Sex steroid replacement + HRT or COCP (combined hormonal contraceptive)
o Unless contraindicated (for example, in women with hormone-sensitive cancer)
o HRT/COCP should be continued until at least the age of natural menopause
o HRT may have a beneficial effect on blood pressure when compared to the COCP
o Both HRT + COCP offer bone protection
o HRT is not a contraceptive
Give examples of progestogen medications
Oral/depot Medroxyprogesterone acetate
Dienogest
Cyproterone acetate
Norethisterone acetate
Give examples of GnRH agonist medications
leuprorelin nafarelin buserelin goserelin triptorelin
Hormonal treatment after surgery for endometriosis - duration + indications
• Short-term
• Long-term
Hormonal treatment after surgery
• Short-term (<6 months) not recommended as there is no evidence that it improves the outcomes of the surgery
• Long-term (>6 months) contraception, secondary prevention
o LNG-IUS
o COCP
o Indication: secondary prevention of endometriosis associated dysmenorrhoea but not for non-menstrual pelvic pain or dyspareunia
Infertile women with endometriosis management
• In infertile women with endometriosis clinicians should nor prescribe hormonal treatment for suppression of ovarian function to improve fertility
• AFS/ASRM stage I/II
o Operative laparotomy – excision or ablation of the endometriosis lesions incl. adhesiolysis rather than diagnostic laparoscopy only – Increases ongoing pregnancy rates
o CO2 laser vaporisation of endometriosis
o Intrauterine insemination with controlled ovarian stimulation within 6 months after surgical treatment – increases live birth rates compared to expectant mx
• Ovarian endometrioma
o Excision of the endometrioma capsule + electrocoagulation of the endometrioma wall
o risks of reduced ovarian function after surgery + possible loss of ovary
o If endometrioma >3cm
No evidence that cystectomy prior to treatment with assisted reproductive technologies improves pregnancy rates
Only consider cystectomy to improve endometriosis-associated pain or the accessibility of follicles
• AFS/ASRM stage III/IV
o Can consider operative laparoscopy instead of expectant management to increase spontaneous pregnancy rates
• Do not prescribe adjunctive hormonal treatment before/after surgery to improve spontaneous pregnancy rates
• Use of assisted reproductive technologies for infertility associated with endometriosis, especially if tubal function is compromised or if there is male factor infertility, and/or other treatments have failed
o GnRH agonists for a period of 3 to 6 months prior to treatment with assisted reproductive technologies – improves clinical pregnancy rates in infertile women with endometriosis
o If undergoing laparoscopy prior to treatment with assisted reproductive technologies complete surgical removal of endometriosis
Post menopausal women with a hx of endometriosis mx
• Surgically induced menopause because of endometriosis estrogen/progestogen or tibolone for at least up to the age of natural menopause
• Postmenopausal women after hysterectomy + a hx of endometriosis avoid unopposed estrogen
o Endometriosis is an oestrogen-depending confition
o Hormonal therapy in women with menopausal symptoms + a hx of endometriosis may reactivate residual disease or produce new lesins
o Balance risk of disease reactivation + malignant transformation of residual disease against the increased systemic risks with combined oestrogen/progestogen or tibolone
What is tibolone and where is it used
- The first “bleed-free” HRT contains a synthetic hormone known as Tibolone, which is taken orally every day
- Combined oestrogen, progestogen and testosterone effects
- Relieves menopausal symptoms, prevents bone loss, and may improve interest in sex
- Normally prescribed at least 12 months after the last menstrual period, so many women switch to these continuous types after taking a sequential HRT
- Has also been shown to be particularly useful in women who are known to have endometriosis and fibroids as it does not appear to stimulate these conditions
Tamoxifen and SSRI SNRI interactions
- Tamoxifen is extensively metabolised via cytochrome P450 2D6 (CYP2D6) to active metabolites, the most significant of which is endoxifen.
- Paroxetine is a potent CYP2D6 inhibitor,
- Fluoxetine is a moderate-to-potent inhibitor, and fluvoxamine and duloxetine are moderate inhibitors.
- Preference should be given to SSRIs/SNRIs with weak inhibitory effects on CYP2D6, such as citalopram, escitalopram, sertraline and venlafaxine
Women on tamoxifen should not take fluoxetine or paroxetine makes tamoxifen ineffective
Velnaflaxine preferred in people taking Tamoxifen
Menopause Treatments for breast cancer survivors
Treatments for breast cancer survivors
• Most clinical guidelines do not recommend oestrogen based treatments
• NAMS (north American menopause society) SSRIs, SNRIs, gabapentin, pregabalin, clonidine, CBT
• UK NICE
o SSRIs, SNRIs, Gabapentine – no better than placebo
o Paroxetine + fluoxetine – will reduce the efficacy of tamoxifen
o Clonidine, venlafaxine, gabapentine
o St Johns wort may improve symptoms but not recommended because of serious drug interactions
• Isoflavones, red clover, black cohosh – not recommended
Atrophic vaginitis mx
Hormonal preparations (oestrogen): Topical and systemic oestrogens are the most efficacious treatment for atrophic vaginitis
• Topical HRT
o Restores vaginal pH
o Works by thickening and revascularizing the vaginal epithelium, so improving lubrication
o Helps to improve urinary symptoms
o Systemic HRT – not recommended as 1st line treatment for those with only vaginal symptoms + no menopausal symptoms
o Around 10-25% of women receiving HRT still have symptoms – will require topical oestrogen in addition to HRT
• Topical treatments:
o Intravaginal cream
Common to have more vaginal discharge with creams
This may be an advantageous SE in sexually active women
o Vaginal gel
o Vaginal tablets
o Vaginal pessary
One vaginal pessary daily for the first 3 weeks
Reducing to one vaginal pessary 2ice a week
o Vaginal ring
Inserted into the upper third of the vagina
Changed every 3 months
Maximum duration of continuous treatment = 2 years
Vaginal oestrogens can be really effective in patients with urinary symptoms
No evidence that topical oestrogens cause endometrial proliferation after long-term use
Low dose topical oestrogen is safe and does not need to be given with systemic progestogens
Women receiving hormonal treatment should be advised to contact their doctor if they experience any vaginal bleeding
Non-hormonal treatments
Lubricants + moisturisers used in those with contra-indications/cannot use oestrogen
Lower efficacy than oestrogen
• Lubricants
• Moisturisers
o Bio-adhesive – attach to mucin and epithelial cells on the vaginal wall – therefore retain water
o Can also lower vaginal pH
o Safe to be used daily
o Should be used regularly rather than during sexual intercourse
+ systemic HRT If co-existent menopausal sx
Asherman’s syndorme mx
• Surgical management
o Hysteroscopic adhesiolysis (sometimes assisted by laparoscopy) – to cut the adhesions of the uterine wall
• Post-op management – re-adhesion prevention
o Chemicals
Hyaluronic acid – acts as a temporary barrier to prevent re-adhesion and may also promote tissue repair
o Splint/balloon insertion to prevent apposition of the walls during the immediate post-operative healing phase
o Weekly in-office hysteroscopy to cut away any newly formed adhesions
o Paediatric Foley catheter
To separate the uterine walls to prevent the recurrent adhesions
Insert into the uterine cavity for 5-7 days with a bag removing the drainage of the uterus
• Uterus restoration therapies
o Oestrogen supplementation
Can be inserted into the uterus as post-op ICUD for 2-3 months – oestrogens induce endometrial proliferation + prevent re-formation of IUA
Repairs + restores the uterine wall, stimulates uterine healing
2 cycles of cyclical oestrogen + progesterone (Specialties guide)
o Antibiotics – to prevent infections + inflammation that may damage the uterus and trigger re-adhesion of the uterine walls
- Mild cases – only require surgical treatment
- Severe cases – may require all 3 approaches
Asherman’s syndrome prevention
• Prevention
o Misoprostol for miscarriage or RCT
o Perform D+C under US guidance rather than blindly
o Early identification of miscarriage – adhesions are more likely to occur after a D+C the longer the period after fetal death
Miscarriage mx >6 weeks pregnant
> 6 weeks pregnant –> EPAU referral
• Threatened miscarriage – expectant management
o Advise a woman with vaginal bleeding + confirmed intrauterine pregnancy with a fetal heartbeat that
If her bleeding gets worse or persists beyond 14 days she should return for further assessment
If the bleeding stops, she should start or continue routine antenatal care
Offer vaginal micronized progesterone 400mg BD to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and a previous miscarriage
If a fetal heart beat is confirmed, continue progesterone until 16 completed weeks of pregnancy
- Complete miscarriage – menstruation will begin in 4-8 weeks, try for another when mentally ready
- Incomplete miscarriage – expectant for 14 days (1st line) , medical or surgical (2nd line)
Miscarriage mx <6 weeks pregnant
<6 weeks pregnant - expectant management, no USS
• Pregnancy test in 1 week
• If positive/symptoms persist – follow up in clinic in 2 weeks
• If RPC – medical/surgical mx
recurrent miscarriage due to APLS mx
RMC
• Low dose aspirin + LMWH if thrombophilia identified (APLS)
APLS
• Symptoms – VTE, arterial thrombosis, thrombocytopenia, RMC, pre-eclampsia
o Assess for features of SLE
• Ix – lupus anticoagulant AB +/- anti-cardiolipin Ab
• Mx
o Acute – warfarin + LMWH
o Chronic – DOAC
o Pregnancy – low-dose aspirin + LMWH
Miscarriage conservative mx
Conservative/Expectant for confirmed miscarriage (70%)
• 1st line treatment - expectant management for 7 to 14 days for women with a confirmed dx of first-trimester miscarriage after the scan at the EPAU
o Expectant management for 7-14 days
o Urine pregnancy test after 3 weeks
If positive – need to be reviewed and considered for either medical or surgical treatment
o Review the condition of the woman at a minimum 14 days after the first follow-up appointment
• Repeat scan after the period of expectant management if the pain and the bleeding
o Have not started (suggesting that the process of miscarriage has not begun) or
o Are persisting and/or increasing (suggesting incomplete miscarriage) – follow up in clinic in 4 weeks
• Consider other management options (medical or surgical) in women with
o An increased risk of haemorrhage (e.g. she is in the late first trimester)
o A previous adverse or traumatic experience associate with pregnancy (stillbirth, miscarriage, antepartum haemorrhage)
o Increased risk from the effects of haemorrhage (if she has coagulopathies or is unable to have a blood transfusion)
o Any evidence of infection
- Offer medical management to women with a confirmed dx of miscarriage if expectant management is not acceptable to the woman
- Conservative management is associated with higher unplanned emergency interventions + blood transfusion rates but no difference in infection rates
Miscarriage medical mx
Medical management of confirmed miscarriage (20-30%)
• 2nd line – expectant failed, pt choice
o If bleeding has not started within 24h of treatment, contact a healthcare professional
• Misoprostol
o Synthetic prostaglandin analogue – binds to myometrial cells to cause cervical softening + dilation + uterine contractions leading to expulsion of tissue
o Vaginal - Missed (800μg, single dose) or incomplete (600 μg, single dose) miscarriage
o Oral - alternative
o Pessary is the most effective, oral tablets are the least effective
• Can cause more pain and bleeding than surgical
o Bleeding can continue for up to 3 weeks
- Analgesia
- Anti-emetics
• Mifepristone no longer given
• Women should take a urine pregnancy test 3 weeks after the medical management of miscarriage
o If worsening symptoms/positive urine test after 3 weeks – return to review that there is no molar or ectopic pregnancy
Miscarriage surgical mx
- If medical failed, pt choice
- Less likely than medical management to lead to emergency intervention, associated with a shorter duration of bleeding + fewer GI SE – no difference in infection rates or need for transfusion
• Clinical indications for surgical mx o Persistent excessive bleeding o Haemodynamic instability o Evidence of infected retained tissue o Suspected gestational trophoblastic disease
• Choice of
o Manual vacuum aspiration (suction curettage) under LA in an OP or clinic setting
Safe, Quick, less painful than sharp curettage
Sexual hx/screening for infection (incl. Chlamydia trachomatis) should be undertaken in women undergoing surgical uterine evacuation
o Surgical management in theatre, under GA
ERPC – evacuation of retained products of conception
- Vaginal or sublingual misoprostol is often used to ripen the cervix to facilitate cervical dilation for suction insertion
- Anti-rhesus D prophylaxis (250IU)
NICE:
o Should be offered to all rhesus -ve women who have had a surgical procedure to manage a miscarriage
o Do not offer anti-rhesus D prophylaxis to women who
Receive solely medical treatment for their ectopic pregnancy or miscarriage or
Threatened/complete miscarriage or
PUL
BCSH
o Administer if mother is rhesus -ve + >12w GA (any method of management)
o Therapeutic termination - anti-D given regardless of method + GA
• Tissue obtained at the time of miscarriage is examined histologically – confirm pregnancy + exclude ectopic pregnancy or gestational trophoblastic disease
