Other Flashcards
Define Female Genital Mutilation.
Female genital mutilation (FGM) involves surgically changing the genitals of a female for non-medical reasons
Where is FGM common?
- FGM is a common cultural practice in many African countries.
- Somalia has the highest levels of FGM in any country.
- Other countries with high rates are Ethiopia, Sudan and Eritrea.
- It also occurs in Yemen, Kurdistan, Indonesia and various parts of South and Western Asia.
What are the types of FGM?
How do we identify cases of FGM?
It is important to recognise risk factors for FGM to identify and ideally prevent cases from occurring.
Two key risk factors to bear in mind are coming from a community that practise FGM and having relatives affected by FGM.
There are scenarios where it is worth considering the risk of FGM:
- Pregnant women with FGM with a possible female child
- Siblings or daughters of women or girls affected by FGM
- Extended trips with infants or children to areas where FGM is practised
- Women that decline examination or cervical screening
- New patients from communities that practise FGM
Women may also present with the complications of FGM.
What are the short and long term complications of FGM?
Immediate complications include:
- Pain
- Bleeding
- Infection
- Swelling
- Urinary retention
- Urethral damage and incontinence
Long term complications include:
- Vaginal infections, such as bacterial vaginosis
- Pelvic infections
- Urinary tract infections
- Dysmenorrhea (painful menstruation)
- Sexual dysfunction and dyspareunia (painful sex)
- Infertility and pregnancy-related complications
- Significant psychological issues and depression
- Reduced engagement with healthcare and screening
What does the Female Genital Mutilation Act 2003 say?
- FGM is illegal unless it is a surgical operation on a girl or woman irrespective of her age:
- (a) which is necessary for her physical or mental health; or
- (b) she is in any stage of labour, or has just given birth, for purposes connected with the labour or birth.
- It is illegal to arrange, or assist in arranging, for a UK national or UK resident to be taken overseas for the purpose of FGM.
- It is an offence for those with parental responsibility to fail to protect a girl from the risk of FGM.
- If FGM is confirmed in a girl under 18 years of age (either on examination or because the patient or parent says it has been done), reporting to the police is mandatory and this must be within 1 month of confirmation.
How should we think of managing FGM?
- Explain UK Law
- If under 18
- Over 18
- De-infibulation
How should we manage FGM in under 18s?
It is mandatory to report all cases of FGM in patients under 18 to the police.
Other services should also be contacted:
- Social services and safeguarding
- Paediatrics
- Specialist gynaecology or FGM services
- Counselling
How should we manage FGM in over 18s? What is the role of de-infublation?
- In patients over 18, there needs to be careful consideration about whether to report cases to the police or social services.
- All acute trusts/health boards should have a designated consultant and midwife responsible for the care of women with FGM
- Specialist multidisciplinary FGM services should be led by a consultant obstetrician and/or gynaecologist and be accessible through self-referral. These services should offer: information and advice about FGM; child safeguarding risk assessment; gynaecological assessment; de-infibulation; and access to other services
- The RCOG recommends using a risk assessment tool to tackle this issue (available on the gov.uk website).
- The risk assessment includes considering whether the patient has female relatives that may be at risk.
- If the unborn child of a pregnant woman affected by FGM is considered to be at risk, a referral should be made.
A de-infibulation surgical procedure may be performed by a specialist in FGM in cases of type 3 FGM. This aims to correct the narrowing or closure of the vaginal orifice, improve symptoms and try to restore normal function.
Is re-infibulation allowed?
Re-infibulation (re-closure of the vaginal orifice) could be requested after childbirth. Performing this procedure is illegal.
Define Asherman’s syndrome
Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
What causes Asherman’s syndrome? What are the complications associated with it?
Intrauterine synechiae or adhesions are caused by trauma to the endometrium. This can result from repeated uterine cavity surgery e.g. dilatation and curettage (D&C), postpartum haemorrhage procedures and infection.
It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).
Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut.
These adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages.
Adhesions may be found incidentally during hysteroscopy. Asymptomatic adhesions are not classified as Asherman’s syndrome.
How does Asherman’s syndrome present?
- can be completely asymptomatic
- menstrual disturbances – mostly amenorrhea
- cyclic abdominal pain - dysmenorrhea
- subfertility
- ectopic pregnancy
- spontaneous miscarriage
- premature delivery
- abnormal placental implantation.
How does Asherman’s syndrome present?
- can be completely asymptomatic
- menstrual disturbances – mostly amenorrhea
- cyclic abdominal pain - dysmenorrhea
- subfertility
- ectopic pregnancy
- spontaneous miscarriage
- premature delivery
- abnormal placental implantation.
What are the investigations for Asherman’s syndrome?
- hysteroscopy – the gold standard for accurate diagnosis and can be used for treatment
- hysterosalpingography (HSG) – the radiological findings of filling defects confirm the diagnosis in 85% of cases. HSG has the added advantage of providing information on tubal patency
- sonohysterography - uterus if filled with fluid and pelvic US performed
