GYNECOLOGIC PROCEDURES AND SURGERY pdf

Therefore, endocervical curettage should be performed in women who are being evaluated for abnormal cervical cytology.Normally, columnar epithelium covers the ectocervix until ado-lescen

of the cervix alone Although cervical cytology may detect dometrial cancer (in 15%–50%), it does not carry the same relia-bility as a screening tool for endometrial neoplasia.

en-SCREENING GUIDELINES

● Initial gynecologic screening at age 18, or when the

indi-vidual becomes sexually active

● Women whose initial smear is negative (without significant atypia) should have a second smear within 1 year to rule

out a false-negative smear

● High-risk women should be screened annually (i.e., those

with a history of early sexual activity or those with ple sexual partners)

multi-● Low-risk women may be screened every 1–3 years at the

dis-cretion of the physician These are women with late sure to coitus, those with only one sexual partner, andwomen after two successive negative annual smears (Someauthorities contend it is too difficult to ascertain low riskand simply recommend annual screening.)

expo-31

GYNECOLOGIC PROCEDURES

AND SURGERY

● Postmenopausal women should receive annual screening.

● Women after hysterectomy should have an initial smear

fol-lowing surgery; if this is negative, cytology should be peated every 3 years

lubri-The objective is to sample secretions from the endocervical canal, the transformation zone, and the vaginal pool The last site

is less productive and, therefore, of lesser priority Sampling is complished by gently wiping away excess mucus and obtaining en-docervical canal samples using the moist cotton swab or cervicalspatula This is smeared onto a glass slide and fixed A spatula with

ac-an endocervical extension, or similar device is used to lightly scrapethe entire transformation zone In those with a small external os, abrush device may be helpful in guaranteeing that endocervical cellsare sampled This sample is spread on a slide and fixed immedi-ately Finally, the vaginal pool may be sampled by using the samespatula (again, fixing immediately) The reporting of cervical cyto-logic results is discussed on p 524

COLPOSCOPY

The colposcope is a binocular microscope of low magnification(10–40) used for direct visualization of the cervix Although col-poscopy does not replace other methods of diagnosing cervical ab-

normalities, it is an important additional tool The patients who most benefit from colposcopy are those with abnormal Pap smears Col-

poscopy is also used to evaluate women who were exposed to DES

in utero and in gynecologic cancer therapy follow-up

Occult neoplasms in the upper cervical canal, where 10% –15%

of cervical cancers develop, cannot be detected by colposcopy Therefore, endocervical curettage should be performed in women

who are being evaluated for abnormal cervical cytology.Normally, columnar epithelium covers the ectocervix until ado-lescence, when it gradually changes to a squamous surface Thetransformation zone can be inspected easily with the colposcope,

and dysplastic surface changes can be identified These include

white epithelium (e.g., sheet of layered metaplastic cells), a mosaicpattern (e.g., sharply outlined cells and cell groups), punctation (e.g.,

vascular tufts between cell clusters), and leukoplakia (e.g., mal pale cell plaques).

abnor-Colposcopy allows recognition of cellular dysplasia and cular or tissue abnormalities not otherwise visible Colposcopy al- lows selection of cancer-suspicious areas for biopsy A green filter accentuates the vascular changes (which frequently accompany

vas-pathologic alteration) Dilute (3%) acetic acid solution is used toremove mucus and to facilitate visualization Other chemical agentsand stains may also be used to improve visualization A camera at-tached to the colposcope facilitates follow-up Colposcope-directedbiopsy decreases the number of false-negative reports and may elim-inate the need for conization of the cervix, a cause of morbidity

To perform colposcopy, proceed as follows

● Insert a speculum and visualize the cervix.

● Cleanse the cervix with 3% acetic acid This removes

ex-cess mucus, blanches the surface, and accentuates normalepithelium

● Focus the colposcope on the cervix, beginning with low

power (usually 13.5) Inspect the squamocolumnar tion (transformation zone) carefully A significantly abnor-mal area usually can be fully outlined

junc-● Take biopsy specimens with a Kevorkian or similar biopsy

forceps, and record the sites most suggestive of cancer

● Consider whether endocervical curettage should be

per-formed

Effective use of the colposcope requires thorough training andextensive experience

EVALUATION OF PATIENT WITH

ABNORMAL CERVICAL CYTOLOGY

In summary, a normal smear requires follow-up as noted previously

Atypical squamous cells of undetermined significance identifies cells that need further studies to identify if they are reactive or neoplas- tic In these cases, if there is clinical infection, treatment against the

offending agent with repeat cytology 6–8 weeks after the infection

is eliminated and the tissue has healed may be all that is necessary

The more ominous nature of atypical glandular cells of mined significance requires an evaluation for endocervical, en- dometrial, tubal, or ovarian pathology.

undeter-Low-grade squamous intraepithelial lesions (LGSIL) include

grade I cervical intraepithelial neoplasia (CIN), also termed mild

dysplasia, and human papillomavirus lesions Whereas high-grade squamous intraepithelial lesion (HGSIL) includes moderate and

severe dysplasia (CIN II and III) Thus, when these reports are turned, prompt colposcopy is warranted Any abnormal areas must

re-be biopsied, and endocervical curettage must re-be performed ble invasive cancer requires immediate colposcopy and biopsy (in-cluding conization if necessary)

Possi-CULDOCENTESIS

(See Ectopic pregnancy, p 311)

SOUNDING THE UTERUS

The uterus may be sounded to determine the patency of the

cervi-cal canal, the presence of cervicervi-cal or uterine lesions that will bleed

on contact, the size of the uterus, the position of the uterine dus, and the direction of the uterine canal (before endometrial

fun-biopsy or other instrumentation) Intrauterine pregnancy must be ruled out before uterine sounding Use a sterile, malleable, cali-

brated (in centimeters) instrument (e.g., Sims or Simpson uterinesound)

Visualize the external cervix with a speculum, and carefully ply an antiseptic solution (e.g., povidone-iodine) Bend the sound to the estimated curvature of the cervicouterine axis After warning the patient of possible slight pain, grasp the cervix (on either anterior

ap-or posteriap-or lip) by a double-toothed Braun ap-or Allis clamp and ert gentle traction toward the introitus, using the nondominant hand.This immobilizes the cervix and straightens the endocervical canal

ex-Use the index finger and thumb of the dominant hand to gently insert the sound in the cervicouterine axis while pressing the third

and fourth fingers against the vulva to brace the hand A slight, sient resistance may be encountered at the level of the internal os

tran-An obvious obstruction is encountered at the vault of the uterine

cavity Exert special care to avoid perforation of the uterus at the

level of the cervicouterine junction (particularly in marked flexion)and at the top of the fundus Note the length of the cervical canal,the direction of the axis, the depth of the uterine cavity, and anyobstruction, distortion, or free bleeding

In the absence of cervical stenosis and extreme flexion of thecorpus, gentle traction and sounding of the uterus cause only a fewslightly menstrual-like cramps Careful patient preparation and anal-gesics, if necessary, make the procedure tolerable

If sounding of the uterus is impossible with the usual ments, it may be initiated using a fine, soft wire probe, followed byHegar dilators (#5–10) The diagnosis of an abnormally wide

instru-internal cervical os (notably incompetent) is confirmed if #8 Hegardilator passes without resistance.

BIOPSIESVULVAR

(See p 588)

CERVICAL

Multiple cervical biopsies may be performed in the office with

lit-tle or no discomfort or danger, using Tischler, Schubert, Kevorkian,

or similar punch biopsy forceps Polypoid lesions may be removed

by torsion or excision (Figs 31-2 and 31-3) For microscopic sis, do not crush the tissue Anesthetics are not required because the

analy-cervix is relatively insensitive to this type of pain.

After detailing the areas to be biopsied by colcoscopy,

immo-bilize the cervix using a tenaculum First biopsy the posterior lip(so bleeding from more anterior biopsies will not obscure the field)

The most frequent biopsy sites are at or near the squamocolumnar junction Place the tissue in fixative (e.g., 10% formalin) immedi- ately Bleeding is variable and unpredictable If necessary, control bleeding by pressure, Negatol, acetone, 5% silver nitrate solution,

or fine catgut sutures

ENDOCERVICAL CURETTAGE

This procedure is commonly used as an adjunct to colposcopy in

an effort to guarantee sampling of the entire endocervix Stabilize

the cervix using a tenaculum or Allis clamp, and curette the cervix throughout its circumference by taking downward strokesfrom the internal to the external os with a Kevorkian or other smallcuret Fix these strips of tissue immediately and submit them forpathologic diagnosis Anesthesia is rarely required, the proceduregenerally is very short (2 min), and bleeding is minimal The prin-cipal complication is uterine perforation (usually at the cervi-couterine junction).

endo-FIGURE 31-3. Three methods of cervical polypectomy

cervici-The most common endometrial biopsy instrument currently used

is a tubular plastic device for aspiration of strips of endometrium.After antiseptic preparation, sound the uterus Next, direct the curet

to the fundus and gently stroke downward against the uterine wall

to the cervix while exerting gentle suction Perform on both rior and posterior uterine walls Place the tissue obtained in fixa-tive immediately

ante-INDUCED ABORTION

DEFINITION, INCIDENCE AND

ASSOCIATIONS

In the United States, elective abortion is persistently controversial.

Our purpose is to provide timely information, not to debate issues

or enter into controversy Therefore, in this summary there is no tempt to influence patients or health care providers for or againstabortion, and none should be inferred The statistical data in the fol-lowing is summarized from the most authoritative source available

at-at the time of writing, (i.e., Koonin LM, Strauss LT, Chrisman CE,Montalbano MA, Bartlett LA, Smith JC Abortion Surveillance—

United States, 1996, Morbidity and Mortality Weekly Report,

July 30, 1999, 48:1–42)

The U.S Centers for Disease Control and Prevention (CDC)

de-fines legal induced abortion as a procedure performed by a licensed physician or someone acting under the supervision of a licensed physician, that was intended to terminate a suspected or known in- trauterine pregnancy and to produce a nonviable fetus at any ges- tational age Absolute numbers of abortions are not as sensitive an

index of utilization by women in the reproductive years as are the

abortion ratio (the number of abortions per 1000 live births per year

in a given age group) and the abortion rate (the number of tions per 1000 women in a given age group per year) Table 31-1summarizes annual data for the United States

abor-U.S legal abortion utilization has stabilized following the cline experienced earlier this decade Whereas those 15 years havethe highest ratio (723), older women (40–44 years) also have a

de-higher ratio (376) of legal abortion Ratios are lowest in women age30–34 years (165) For over a decade, those with highest fertilityrates (age 20–34 years) have had a stable abortion ratio Rates arehighest for women age 20–24 years (38%) and lowest at the re-productive extremes 15 years (2%) and 40–44 years (2%).

Associations with legal abortion utilization include age, race, and

marital status Women 25 years have
50% of legal abortions, and32% are performed in the 20–24 year age group White women com-prise⬃57% of women having legal abortions; but the white ratio of

202 is less than the ratio in black women (555), and women of otherraces (360) The legal abortion rate for black women (31%) is 2.6times the rate for white women (12%) Unmarried women have 78%

of legal abortions, more than 8-fold that of married women.Most (54%) were obtaining a legal abortion for the first time,although 18% had at least two prior abortions No previous livebirths had occurred in 43%, and⬃87% of those having a legal abor-tion had2 previous live births More than one half of all abor-tions (55%) were performed at 8 weeks of gestation, and ⬃88%were performed before 13 weeks Approximately 4% of abortionswere obtained at 16–20 weeks, and 1.5% were obtained at 21weeks Younger women (i.e., women aged 24 years) were morelikely to obtain abortions later in pregnancy than were older women.Currently, nearly all (98%) of abortion are performed by curet-tage Less than 0.5% are by intrauterine saline or prostaglandin ad-ministration Complete data are available for 1992 when 10 womendied as a result of complications from legal induced abortion(a case-fatality rate 0.7 abortion-related deaths per 100,000 legalinduced abortions)

The most controversial abortions are totally elective (patient mand) Social indications for interruption of pregnancy are proba- bly the next most debated indications and cover a broad spectrum:

de-preservation of mental health, excessive family size, poverty, cest, and rape

Perhaps the least controversial are those termed “medically dicated.” Examples of medical diseases said to require interruption

in-of pregnancy to preserve maternal life or vital functions includeneuropsychiatric disorders (authorities disagree regarding qualifi-cations), bilateral renal insufficiency, chronic resistant pyelonephri-tis, class III or IV cardiac disease (e.g., intractable atrial fibrillation,coronary occlusion), marked impairment of pulmonary ventilation(vital capacity of 1400 mL in the average-size person), progres-sive loss of vision or Kimmelstiel-Wilson syndrome in patients with diabetes mellitus, thromboembolic disorders, severe hemo-globinopathies, gammaglobulinopathies, clotting defects, severe ul-cerative colitis, invasive cervical cancer, and advanced breast car-cinoma

Obstetric complications that seriously affect the fetus when

abortion should be considered include rubella before 12–14 weeksgestation, severe isoimmunization, fetuses with known morphologicdefects (e.g., anencephaly, acardius), and fetuses with known con-genital disorders (e.g., Tay-Sachs disease, osteogenesis imperfecta,trisomy 13)

LABORATORY STUDIES

Ultrasound scanning both confirms the pregnancy and aids in

de-termination of gestational age If no fetal sac or fetal heartbeat ispresent, a qualitative hCG is performed, and if positive, a quanti-

tative value obtained An hCG of 1750, in the absence of a fetal sac should alert the physician to the possibility of an ectopic preg- nancy.

COUNSELING

The provider has the responsibility to explain the reputed tages, disadvantages, and alternatives of elective abortion, just as with other procedures Additionally, the patient should be assured

advan-of continued empathetic quality care whatever her decision.

The patient must be informed about the nature of the procedureand its risks, including possible infertility or even continuation ofpregnancy All reasonable alternatives must be explored The rights

of the spouse, parents, or guardian vary considerably from state tostate but must be considered The patient’s permission must be ob-tained State or provincial laws must be obeyed, with special ref-erence to patient age, residence, indications for abortion, duration

of pregnancy, consent, and consultations required or advisable.Protracted guilt feelings for the loss of the fetus and remorsemay result from induced abortion, particularly when religious andsocial conflicts complicate the decision to abort The reported inci-

dence of serious emotional sequelae following induced abortion is

,5% Follow-up and special care for those adversely affected should

be afforded the patient

METHODS

Several trends are discernable in the techniques employed for legalabortion There is increasing interest in, as well as utilization of,

nonsurgical abortion The percentage of legal abortions performed

by curettage (including D & E) has increased from 89% to 99%, whereas abortion by other surgical means has declined (intrauter-

ine instillation from 10% to 0.4%, and hysterectomy and terotomy from 0.6% to 0.01%) Some authorities recommend thatall patient receive prophylactic antibiotics before the procedure.Early Medical (Nonsurgical) Abortion

hys-Mifepristone (RU486), which appears generally safe and effective

8 weeks gestation, is being used for early pregnancy terminationelsewhere in the world and has just received FDA approval for use

in the US Additionally, there appears to be increasing use ofmethotrexate, misoprostol, and a combination of the two, to per-form early medical abortions in the US

Vaginal Evacuation

Two main techniques are used for vaginal evacuation of pregnancy,

suction curettage and D & C The stated advantages of suction curettage (compared to D & C using standard curets) are that suc-

tion curettage is more rapid (3 min average), less cervical dilation

is necessary (thus, less likelihood of cervical tears and an petent cervix), fewer failed abortions result, less anesthesia andanalgesia are required, blood loss is less, infection is less common,and there is less trauma to the uterus (protection of the basalis andmuscularis layers makes traumatic amenorrhea and intrauterine ad-hesions less likely)

incom-Very early abortion (first 3–4 weeks of gestation) by

low-pressure suction curettage is accomplished using a 4–5 mm ble plastic cannula without cervical dilatation or anesthesia This is

flexi-termed menstrual extraction or menstrual regulation This

proce-dure has a relatively high rate of failed abortion and is cated in women with acute cervicitis or possible salpingitis

contraindi-Suction curettage requires cervical dilatation as well as some form of anesthesia (e.g., paracervical block) when performed at

6–12 weeks gestation (Fig 31-4) However, cervical dilatation can

be accomplished using osmotic dilators (e.g., segments of

Lami-naria) When dry, osmotic dilators are small (2–3 mm diameter),but the material is very hygroscopic and capable of expanding to2–3 times its original diameter The dilators must remain in thecervix for at least 6–8 h to reach full size Synthetic osmotic dila-tors also are available The stated advantages of this method are lesspain (compared to mechanical dilatation) and fewer cervical lacer-ations A disadvantage is that the dilators must be placed in thecervix some hours before the procedure

After 12–13 weeks of pregnancy, suction curettage is usuallyperformed on an outpatient basis in an operating suite These laterterminations (generally up to 20 weeks—called dilatation and evac-uation, D & E) require several osmotic dilators or graduated me-chanical dilators, a larger suction cannula, and forceps to complete

FIGURE 31-4. Suction method for therapeutic abortion.

evacuation Although this technique has fewer complications thanthe various methods for induction of uterine contractions and ismore rapid than induction of contractions, it requires greater tech-nical expertise The long-term effects (primarily of possible cervi-cal trauma) remain unknown.

IV sedation, as well as a NSAID, is commonly used in officesettings where the procedures are performed under paracervicalblock In surgicenters, terminations are more often performed withgeneral anesthesia As noted previously, most patients receive pre-operative antibiotics and that generally is continued for 3 doses post-operative Methergine 0.2 mg po Q 6 h for 6 does is used to assist

in uterine involution

INDUCTION OF UTERINE

CONTRACTIONS

With Live Fetus

The various techniques of second trimester abortion by induction

of contractions include intraamniotic saline infusion (100–200 mL20% solution), intraamniotic infusion of prostaglandin (PGF2a, 40mg), intravaginal prostaglandin vaginal suppositories (E2, 20 mg),and intramuscular 15-methyl PGF2 The coagulation system is al-tered temporarily by injection of hypertonic saline (decreased fib-rinogen and platelets, increased fibrin degradation products) and thepatient’s fluids and electrolytes must be monitored carefully

The noninvasive techniques (using prostaglandins) require

less technical expertise and have a lower morbidity However,prostaglandins should not be used in patients with asthma or inthose who have had prior uterine surgery The prostaglandins usu-ally cause marked gastrointestinal side effects (nausea, vomiting,and diarrhea), which require appropriate premedication How-ever, the success rate is
95%

With Dead Fetus in Second or Third Trimester

PGE2suppositories are most successful for use after spontaneousfetal death when it occurs in the second or third trimester As withthe other prostaglandins, PGE2suppositories must be repeated, re-sult in a rapid abortion (8–12 h), and include all the side effectsnoted above, plus chills and fever

Hysterotomy and Hysterectomy

Abdominal or vaginal hysterotomy, major surgery, has the

disadvan-tage of much higher morbidity and should be avoided if possible.

Hysterectomy, feasible up to 23 weeks gestation, may be warrantedfor patients requiring hysterectomy for other reasons.

FOLLOW-UP OF PATIENTS AFTER

INDUCED ABORTION

Rh o immune globulin prophylaxis (e.g., RhoGAM) should be

ad-ministered72 h after abortion if the patient is Rh negative cept when the father is Rh negative) For the first trimester abor-tion, the recommended dose of Rh immune globulin is 50 m g IM,and for second trimester abortion, the dose is 300 m g IM As withterm gestations, if there is evidence of fetal–maternal hemorrhage,additional Rh immune globulin should be given

(ex-The patient should take her temperature daily and avoid coitus,douching, and use of vaginal tampons until her follow-up visit (usu-ally⬃2 weeks) Effective contraception should be made availableaccording to the patient’s needs and desires She should report fever,unusual bleeding, or flulike symptoms at once She should be of-fered counseling and support similar to that following term preg-nancy and delivery Follow-up care should include pelvic exami-nation to rule out continued pregnancy, endometritis, parametritis,salpingitis, or failure of involution

COMPLICATIONS

The major complications of induced abortion include uterine

per-foration, pelvic infection, hemorrhage, and embolism The ity rate for legal abortions in the United States is 0.7/100,000 (v.

mortal-⬃9/100,000 for delivery) The longer the duration of gestation, the

greater the threat to the woman’s life

USE OF VAGINAL PESSARIES

The vaginal pessary is a rubber or plastic prosthesis, often with a

metal band or spring frame The usual widely accepted indications

for pessaries include poor-risk patients or those who refuse surgery for uterine prolapse or other vaginal hernias, aiding preoperative healing of cervical stasis ulcerations associated with cervical pro- lapse, nonoperative reduction of cystocele or rectocele, and to fa- cilitate the evaluation and performance of hysteropexy (by holding

the uterus in position) A vaginal pessary is probably most usefulfor the support of a prolapsed uterus or cervical stump

Pessaries are contraindicated in patients with acute genital tract

infections and in those with adherent uterine retroposition In mostcases, adequate anterior support and a reasonably good perinealbody are required Otherwise, the pessary may slip from behind thesymphysis to be extruded from the vagina

The various useful types of pessaries are shown in Figures 31-5and 31-6 The Hodge pessary (Smith-Hodge, or Smith and other

FIGURE 31-5. Types of pessaries.

variations) is an elongated curved ovoid that supports the uterus ter repositioning The Gellhorn and Menge pessaries are for cor-rection of marked prolapse when the perineal body is adequate TheGehrung pessary rests in the vagina, cradling the cervix betweenthe long arms, while it arches to the anterior vaginal wall to reduce

af-a cystocele Haf-ard or soft ring pessaf-aries (af-as well af-as the hollow plaf-as-tic ball or sponge rubber bee cell) distend the vagina, elevate thecervix, and reduce cystocele and rectocele by direct pressure.Inflatable pessaries function similarly If the perineum is inadequate,

plas-FIGURE 31-6. Bee cell pessary.

these pessaries may require a perineal belt and pad for support TheNapier pessary has a cup–stem arrangement supported by a belt andaffords uterine support for a prolapsed cervix or uterus when theperineum is incompetent.

Pessaries are never curative, but they may be useful for months

or years of palliation Nonetheless, their use should be properly pervised A neglected pessary may encourage genital infection(s)

su-and may even cause fistulas If the pessary is displaced, becomesuncomfortable, or requires cleaning, it must be removed The fre-quency of removal varies depending on the pessary and the patient’sstatus To preserve the vaginal mucosa, a bee cell or inflatable pes-sary should be removed and cleaned nightly Other pessaries may

be left in longer Acetic acid douches help to maintain hygiene whilewearing a vaginal pessary

When pessaries are fitted, the patient should be shown how to insert, remove, and clean it Patients should be warned of difficul- ties (e.g., pessaries may cause infection, pressure necrosis, and ul-

ceration or fistulas) Patients should be closely supervised If notcontraindicated, estrogen cream will assist in preserving the vagi-nal mucosa

FIGURE 31-7. Diagrammatic representation of hysteroscope in use

nec-This technique is useful for removal of a foreign body (e.g., a

intrauterine device), diagnosis of abnormal uterine bleeding (a polyp

or other small tumor not discovered by other techniques), biopsy ofspecific sites (e.g., D & C may miss areas of endometrial cancer),lysis of intrauterine synechiae (i.e., Asherman’s syndrome), someinfertility investigations, removal of polypoid leiomyomas, and inoperative management of a subseptate uterus

Contraindications to hysteroscopy include pregnancy, acute vicitis or salpingitis, the presence of STDs, and hemorrhage

cer-GYNECOLOGIC SURGERY

DILATATION AND CURETTAGE (D & C)

Dilatation of the cervix and curettage of the endometrium (D & C)

is the most common gynecologic surgical procedure If D & C is

being performed for suspected endometrial or cervical cancer, imens must be taken first from the endocervix (before sounding anddilatation) and submitted separately from those of the endometrium.This is fractional curettage Because even more information may beacquired by hysteroscopy and endocervical curettage, that proce-dure is increasingly utilized The indications for D & C are sum-marized in Table 31-2

spec-D & C is almost always accomplished in office or outpatientsurgical settings For D & C, the patient is placed in the dorsallithotomy position Although local anesthetics (e.g., paracervicalblocks) are most commonly used, sedation, or general anestheticoccasionally will be necessary

The usual steps in a D & C are as follows Repeat the pelvic

examination Cleanse the vagina and perineum with an antisepticand place the drapes Insert a weighted speculum into the posteriorvagina Visualize, then grasp the cervix with a tenaculum or Allisclamp Curette the endocervical canal with a Kevorkian or similarcurette Sound the uterus Dilate the cervix using progressive