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MRCOG PART 2 SBAs and EMQs

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Essay 354

354 Posted by Nick M.

a .        Enquiry should be made as to the reasons for requesting sterilization, and her knowledge of currently available methods – she might not know that her partner is able to have vastectomy.

 

A past obstetric history and mode of delivery is important as previous caesarean sections may make laparoscopic surgery difficult. In addition to this additional care must be taken when counselling women who do not have children as retrospective studies have shown a high incidence of regret.

 

It is important to enquire about current gynaecological symptoms including details of menstruation, smears and symptoms of prolapse. Menorrhagia may be an indication for alternate forms of contraception such as the LNG-IUS (Mirena). Abnormal smears or other significant gynaecological pathology such as fibroids or prolapse may mean that hysterectomy is a more appropriate treatment.

 

It is also important to enquire about current contraception as effective methods of contraception prior to sterilisation reduce the chances of undiagnosed luteal pregnancies.

 

A past medical/surgical history may reveal contra-indications to general anaesthetic. Previous gynaecological surgery, especially laparotomy or surgical treatment for ectopic pregnancies may make the laparoscopic approach difficult. This allows the woman to be informed of the increased risk of laparotomy.

 

A general physical examination will ensure the person is fit for surgery. A pelvic examination / bi-manual examination will help rule out adnexial masses and large fibroids. This ensures the surgeon is fully informed and can plan the appropriate procedure.

 

b.         Women should be informed of the advantages and disadvantages of all metods of sterilisation. They should also be informed of alternate long-term reversible contraception available. Discussion should include the advantages, disadvantages and failure rates of each method.

Tubal occlusion and vasectomy should be discussed so that women know there is an option. Women should be informed that there is less chance of future pregnancy following vasectomy.

They should be informed of the method of access and the method of tubal occlusion to be used. It is important they know why this method has been chosen and they should also be informed of alternate methods if the intended method is not successful. In this case a brief explanation of the laparoscopic procedure using Filchie clips should be given. It is also important that they understand that a (mini) laparotomy may be required if the laparoscopic approach is unsuccessful.

Women, particularly those at increased risk (previous abdominal surgery / obese / thin ) should be informed of the risks of laparoscopy and requiring laparotomy

She should be informed that serious risks include; Failure, resulting in unplanned pregnancy - the lifetime failure rate is 1 in 200; The possibility of a future pregnancy occurring in the fallopian tube if failure occurs; Failure to gain entry to the abdomen;Uterine perforation.Injuries to the bowel, bladder or blood vessels are serious but infrequent risks - 3 in every 1000 and even death, one woman in every 12 000 undergoing laparoscopy dies as a result of the procedure.

 

She should be informed that laparoscopy is frequently associated with bruising and shoulder-tip pain.

 

Finally all this information must be given in the form of a leaflet which can be read after the consultation.

 

c.         A pregnancy test is mandatory prior to the operation although it should be recognised that this may not pick up early pregnancies.

 

Tubal occlusion can be performed at any time during the menstrual cycle, provided that the clinician is confident that the woman has used effective contraception up to the day of the operation. If this is not the case, the operation should be deferred until the follicular phase of a subsequent cycle.

 

The woman should be advised to use effective contraception until her next menstrual period.If she does not have periods the packet should be finished. IUCD’s should be left insitu until the next period, of for 3 weeks following the procedure.

 

The clips should be placed correctly by an appropriately trained / supervised surgeon and the use of diathermy should be avoided as there are increase rates of fistula formation reported after diathermy.

 

Finally if there is any doubt about the efficacy of the procedure, the woman should be advised to continue effective contraception until a HSG is performed. 

Posted by Sailaja C.

 

a)(a) Discuss and justify the information you will obtain from the history and clinical examination [7 marks].

 

Detailed menstrual history is taken which should include regularity, cycle length, flow and LMP as irregular cycles are associated with increased incidence of luteal phase pregnancy. Last menstrual Period helps to schedule the sterilisation during the post menstrual period to avoid luteal phase pregnancy. The history of menorrhagia may suggest LNG IUS as an alternative method of contraception.

 

The details of previous child births are taken. The mode of delivery is important as caesarean delivery is associated with increased risk of bowel injury during laparoscopic sterilisation. The timing of child birth is noted as sterilisation after recent child birth is associated with regret and increased failure rates. She should be asked if she is certain about her decision and if her family is complete .

 

The contraceptive history is taken with details of method of previous, present contraception. Complaince and concerns regarding the present contraception is noted along with her expectations. This information allows provide advice regarding continuation of contraception till the next period.

 

Sexual history is taken with particular details of unprotected sexual intercourse to estimate the risk of pregnancy and advise regarding protection against pregnancy at the time of sterilisation by provision of emergency contraception if required.

 

Previous history of laparotomy may increase the risk of bowel injury during laparoscopy.

 

BMI is noted. Examination is performed to exclude abdominal and pelvic adnexal masses which require additional procedures.

 

Obesity may be a risk for failed entry of abdominal cavity.

 

(b) Describe your counselling with specific reference to laparoscopic sterilisation [9 marks].

 

She should be informed that majority of the female sterilizations are performed as a day case procedure under general anaesthesia although it can be performed under local anaesthesia.

 

It is to be explained that the procedure is permanent and irreversible method of contraception. Although reversal of sterilisation is possible , it is associated with a variable rate of success ( 27-97%). Expensive and not covered by NHS.

 

It is ensured that the woman is certain of her request and her family is complete.

 

The details of the laparoscopic sterilisation are provided which should include gas insufflation with verees needle, introduction of telescope through umbilicus and tubal occlusion by application of Flishie clips with another instrument in a simple language. She should be informed that hysteroscopic tubal occlusion is an alternative which is under evaluation.

 

The minor and frequent risks are explained which are shoulder tip pain and abdominal discomfort. Informed that topical application of local anaesthesia to the fallopian tubes whenever mechanical occlusive devices are being applied which significantly reduces post-op pain scores and post-op requirement of opiates. Intra-peritoneal instillation of local anaesthetic after the procedure may also be effective.

 

The serious risks associated with laparoscopy are injury to bowel, bladder,vessels with a frequency of 3:1000 and a risk of death of 1:12,000

 

The possibility of requiring laparotomy should be informed (1.4 - 3.1 / 1000), particularly if previous abdominal surgery or overweight.

Other options should be given such as option of vasectomy which can be done under LA and is associated with fewer operation related risks and a lower failure rate than tubal ligation (I in 2000) vs 1 in 200. Long acting reversible contraceptive options are informed such as IUCD, LNG IUS implants which are effective methods of contraception and avoid aneasthetic and surgical risks associated with laparoscopic sterilisation.

 

In case of failure of sterilisation the risk of ectopic pregnancy should be informed and advised to seek early medical help if she thinks that she is pregnant or has abnormal abdominal pain or vaginal bleeding.

 

Information leaflets are provided.

 

  1. Which measures will you take to minimise the risk of pregnancy following sterilisation? [4 marks]

     

The causes of failed sterilisation resulting in pregnancy include, luteal phase pregancy, incorrect application of Flishie clips and tubal recanalisation.

 

The menstrual history is reviewed on the day of surgery. If she misses her menstrual period procedure should be rescheduled to be performed during post menstrual phase .

 

Pregnancy test should be done on the day of procedure which will not exclude luteal phase pregnancy. Luteal phase procedures are avoided. Uterine currettage should not be undertaken on the day of surgery.

 

She should be advised to follow effective contraception till the day of surgery which should be continued till her next menstrual period. IUCD should be removed after the next menstrual period.

 

The procedure should be perfomed by the surgeon with appropriate training and under supervision. All equipment is tested and appropriately maintained

Hulka clips and diathermy should be avoided as they are associated with high failure rates. Filshe clips should be applied 1-2cm from the cornua, at right angles, encasing the full width of the tubes

Essay354 Posted by Chetna K.
Ans a) Her obstetric history will tell about her parity as she may wish to have more children later. Knowledge of her mode of deliveries is important since if she has previous cesarean section/s there may be problem with the laproscope entry during surgery. Her last child birth should be known as this will decide about the timing. Puerperal sterilization cant be done laproscopically. Age of her children should be known as she may regret her decision later in case of any mishap. If she is lactating she should be made aware that sterilization wont have any effect on that. Her menstrual history will tell about any problems with her cycles , regularity, flow as she may be counseled for alternate LARC methods e.g Mirena insertion for menorrhagia. Her LMP is important to know as luteal phase sterilizations must be avoided due to risk of pregnancy. Her contraceptive history will help in advising her to continue the method till next menstrual cycle. If she is practicing LAM( lactation amenorrhea method) for this, pregnancy should be ruled out. Her medical and past surgical history is important to rule out any contraindications . This opportunity should be used to confirm cervical smear history also. Clinical examination will suggest her BMI, if on higher side (>30 kg/m2) difficult laproscope entry is anticipated .Her BP if high should be controlled before surgery. Any chest infection should be ruled out. P/A exam is mandatory to rule out any abdominal or pelvic masses and presence of any scar. P/S exam will rule out any cervical or vaginal pathology and will allow the swabs to be taken if infection suspected. P/V exam will help to know the size of uterus, its mobility and position and presence of any adnexal masses and confirming IUCD if that is the method used. Ans b) It is important to confirm that she is sure of her decision. She should be made aware that it is the permanent method and though reversal is possible, the success rates are poor (~30%), and not funded by NHS. She wont be able to bear any more children. If she wants to do it with termination of pregnancy, there is evidence that regret rates are more. It is done as day case and she will be allowed to go home in few hours if everything is normal. Laproscopic method is most commonly used , hysteroscopic ligation is the alternative method but not used routinely. Details of the procedure including the incision, method of occlusion ( filshie clip / falope rings/diathermy ) is explained. She should be counseled regarding serious risks involved, injury to bowel with incidence of 4 in 1000, injury to bladder (2-3 in 1000),and to ureter, and major vessels. Risk of death 5 in 100,000. . Failure rate should be quoted clearly, 1 in 200. If fails, increased risk of ectopic pregnancy is there. Failure to gain entry can be there.Frequently occurring risks are shoulder tip pain and bruises. Advantages of laproscopic method are less operating time, short hospital stay, early recovery, small incision (cosmetic). Disadvantages are increased risk of visceral and vascular injury, expertise is required, costly equipment , knowledge of energy source , adequately trained assistants and O.T staff. Though the procedure doesn’t cause menstrual problems, there are increasd hysterectomy rates due to this. There is risk of converting the procedure to laprotomy if complication occurs. Alternate methods for long term contraception including their pros and cons are explained, LNG- IUS, estrogen implants, Cu IUD , DMPA( depot medroxyprogesterone acetate) injections and vasectomy . She should be explained that vasectomy is comparatively simple operation and associated with less failure rates ( 1 in 2000) . Type of anesthesia is explained local or general according to local protocol. Instillation of LA over the tubal area if falope rings are used will reduce post- operative pain. Whatever contraception she is using at present need to be continued till her next menstrual cycle. For follow- up she can go to her GP if required ( abdominal pain, vaginal bleeding or doubt of pregnancy). Finally she should be given information leaflet to read at home and come back if any doubt. Ans c) To minimize the risk of pregnancy, her LMP and contraceptive method need to be enquired carefully. Luteal phase sterilization should be avoided and done in follicular phase. She should use effective contraception till next menstrual cycle. Urine pregnancy test should be done before surgery but that doesn’t necessarily rule out pregnancy. Filshie clip when applied should include the whole thickness of the tube. Routine use of two filshie clips is not recommended. Curettage of uterine cavity at the time of procedure is not recommended.
ADIL Posted by Adil H.

 

A healthy 37 year old woman has been referred to the gynaecology clinic because she wishes to be sterilised. (a) Discuss and justify the information you will obtain from the history and clinical examination [7 marks].

 

 

a)      In the history I will ask about her parity , has she completed her family , does she have children, is she in a stable relationship , the duration of her relationship. This is important because sometimes request for sterilization may be perceived as an escape to other issues in her life , in other words look for hidden agenda.

Her menstrual history cycle length, duration of periods, any excessive bleeding, or oligomenorrhea must be recorded as sometimes these problems may be attributed to the procedure .  

A detailed history of current contraception method. If she is using combined oral contraceptive pills, leaving these, may un mask underlying cycle disorders, IUCD usage , history of  pelvic infection. I will inquire about any, specific reasons to resort to sterilization, whether she has tried or heard of mirena , Implanon, Cu IUDs which provides long term contraception and also success rate is eqvivalent to sterilization more so these are reversible methods.  Is it the current method side effects or method failure, if yes then has she required termination.

Past medical history will include presence of chronic medical conditions like diabetes mellitus, asthma, hypertension , any other problems is she on any medication like warfarin, or coc pills, which may need to be changed before surgery or stopped as in the case of coc pills.  History of smoking.

Surgical history, pelvic surgery like caesarean section, laparotomy, which potentially increase the entry related injuries associated with laparoscopic sterilization.

In the family history presence of ovarian cancer is important as in BRCA 1  families it is now recommended that risk reduction ovarian surgery may be performed 5 years before the onset of cancer in the first degree relative, or after completion of family.

On examination I will look at the general health, vital signs, pallor, enlarged thyroid which may give rise to problems in intubation. Her BMI if > 40 then I will seriously counsel her to adopt alternative methods of long term contraception to avoid risks of surgery.

In addition, I will perform abdominal examination to look for previous scars, position of the umbilicus , any un diagnosed pathology like hernia etc. This will help me to .assess, the risk involved and plan the surgical approach. If help of a senior consultant is required then it will be arranged.

 

 

b. Describe your counselling with specific reference to laparoscopic sterilisation [9 marks].

 

I will talk to her regarding the procedure , explain to her in simple layman terms the pelvic anatomy, and with the help of diagram will show her  that a small incision will be required at the naval and another one over the bikini line to facilitate the passage of instruments which will enable us to perform the surgery , in addition she will be able to see the procedure if she is awake on monitors. She will require general anaesthesia or local if expertise is available.

 That tubes will be clipped which will result in blockade and loss of fertility. I will also explain that this is an irreversible method therefore she needs to plan her decision very carefully after considering all pros and cons , and alternative methods . In addition it is a good time to explain that vasectomy in the partner is much more safer and more successful.  I will provide her with information leaflets in preferably in the language she understands.

 

It will be explained to her that in the long term the failure rate is known to be 1 in 200 ,  and there is risk to the bowel , urinary bladder and major blood vessels, which are 0.4/1000, 0.2/1000, 0.2/1000, and mostly these are entry related.  In case of failure there is an increased chance of ectopic pregnancy.

In case of damage to the above structures which usually occurs at the time of entry in to the abdomen , she may require a laparotomy and there may be requirement of blood transfusion. All these will be fully explained at the time  of consent preoperatively as well.

 

It is procedure which has excellent results in trained hands , and requires day care admission, which means that she will be able to go home the same day.

There will be pain but usually enough to be controlled by NSAIDS.

 

 

(c) Which measures will you take to minimise the risk of pregnancy following sterilisation? [4 marks]

The woman must not be pregnant at the time of surgery. There fore a pregnancy test may be done to exclude this , if she is sure that her cycles are regular and there is use of some other method of contraception like an iucd it may be removed later.

 

 The proper identification of the patient is important if there are previous surgeries, previous history of pelvic infection, endometriosis the  adhesions may obscure the correct visualization of the pelvis and inadvertently

Round ligaments may be ligated.

 

The use of filshie clips is associated with the best long term success rates , where as hulka clips, band ligations, are no more recommended, due to high failure rate and intraoperative complications. NICE recommends use of Filshie clips. Diathermy should not be used as it can give rise to fistulous tracts.

ADIL Posted by Adil H.

 

A healthy 37 year old woman has been referred to the gynaecology clinic because she wishes to be sterilised. (a) Discuss and justify the information you will obtain from the history and clinical examination [7 marks].

 

 

a)      In the history I will ask about her parity , has she completed her family , does she have children, is she in a stable relationship , the duration of her relationship. This is important because sometimes request for sterilization may be perceived as an escape to other issues in her life , in other words look for hidden agenda.

Her menstrual history cycle length, duration of periods, any excessive bleeding, or oligomenorrhea must be recorded as sometimes these problems may be attributed to the procedure .  

A detailed history of current contraception method. If she is using combined oral contraceptive pills, leaving these, may un mask underlying cycle disorders, IUCD usage , history of  pelvic infection. I will inquire about any, specific reasons to resort to sterilization, whether she has tried or heard of mirena , Implanon, Cu IUDs which provides long term contraception and also success rate is eqvivalent to sterilization more so these are reversible methods.  Is it the current method side effects or method failure, if yes then has she required termination.

Past medical history will include presence of chronic medical conditions like diabetes mellitus, asthma, hypertension , any other problems is she on any medication like warfarin, or coc pills, which may need to be changed before surgery or stopped as in the case of coc pills.  History of smoking.

Surgical history, pelvic surgery like caesarean section, laparotomy, which potentially increase the entry related injuries associated with laparoscopic sterilization.

In the family history presence of ovarian cancer is important as in BRCA 1  families it is now recommended that risk reduction ovarian surgery may be performed 5 years before the onset of cancer in the first degree relative, or after completion of family.

On examination I will look at the general health, vital signs, pallor, enlarged thyroid which may give rise to problems in intubation. Her BMI if > 40 then I will seriously counsel her to adopt alternative methods of long term contraception to avoid risks of surgery.

In addition, I will perform abdominal examination to look for previous scars, position of the umbilicus , any un diagnosed pathology like hernia etc. This will help me to .assess, the risk involved and plan the surgical approach. If help of a senior consultant is required then it will be arranged.

 

 

b. Describe your counselling with specific reference to laparoscopic sterilisation [9 marks].

 

I will talk to her regarding the procedure , explain to her in simple layman terms the pelvic anatomy, and with the help of diagram will show her  that a small incision will be required at the naval and another one over the bikini line to facilitate the passage of instruments which will enable us to perform the surgery , in addition she will be able to see the procedure if she is awake on monitors. She will require general anaesthesia or local if expertise is available.

 That tubes will be clipped which will result in blockade and loss of fertility. I will also explain that this is an irreversible method therefore she needs to plan her decision very carefully after considering all pros and cons , and alternative methods . In addition it is a good time to explain that vasectomy in the partner is much more safer and more successful.  I will provide her with information leaflets in preferably in the language she understands.

 

It will be explained to her that in the long term the failure rate is known to be 1 in 200 ,  and there is risk to the bowel , urinary bladder and major blood vessels, which are 0.4/1000, 0.2/1000, 0.2/1000, and mostly these are entry related.  In case of failure there is an increased chance of ectopic pregnancy.

In case of damage to the above structures which usually occurs at the time of entry in to the abdomen , she may require a laparotomy and there may be requirement of blood transfusion. All these will be fully explained at the time  of consent preoperatively as well.

 

It is procedure which has excellent results in trained hands , and requires day care admission, which means that she will be able to go home the same day.

There will be pain but usually enough to be controlled by NSAIDS.

 

 

(c) Which measures will you take to minimise the risk of pregnancy following sterilisation? [4 marks]

The woman must not be pregnant at the time of surgery. There fore a pregnancy test may be done to exclude this , if she is sure that her cycles are regular and there is use of some other method of contraception like an iucd it may be removed later.

 

 The proper identification of the patient is important if there are previous surgeries, previous history of pelvic infection, endometriosis the  adhesions may obscure the correct visualization of the pelvis and inadvertently

Round ligaments may be ligated.

 

The use of filshie clips is associated with the best long term success rates , where as hulka clips, band ligations, are no more recommended, due to high failure rate and intraoperative complications. NICE recommends use of Filshie clips. Diathermy should not be used as it can give rise to fistulous tracts.

ADIL Posted by Adil H.

Sorry i pasted my answer twice , i appologise for the inconvineance to the examiner.

ur Posted by urooj M.

a) Ask about age and parity, how many male/ female kids. Wheather her family is complete or wants to reproduce more. stability of relation with partner as it is irreversable procedure.

why she wants sterlization. Does she know other methods of contraception including the long term methods. Is she having any problem with current method of contraception. Does she has any menstrual irregularity and beleives sterlisation to cure it.

 Does she know about vasectomy. Both partners should see the doctor before decision making.Should know about the failure rate of 1:200.

Obstetric history including mode of delivery and age of last born. as LSCS will cause adhesions and foresee any complications including bowel/ bladder damage. Any history of endometriosis/ dysmenorrhoea and she must know that sterlisation will not cure it but poses difficulty in the procedure of BTL.

Any chronic illness, previous scar, PID because it will be carried out under general anaesthesia.

Inquire LMP because you have to rule out pregnancy beforeit.

Examine height, weight and calculate BMI. General physical, abdominal and pelvic examination to rule out any abnormality.

b) Different methods available for sterlisation. Explain the procedure of laparoscopic sterlisation including need for general anaesthesia. Different techniques available like fallop ring, filshie clips, electrocautery. and clips are the best.

It is a day case procedure and can go home same day.

Certain risks are associated with it  like failure to enter the abdominal cavity in case of obesity, or adhesions. subcutaneous emphysema, bladder , bowel/ vessel injury ......risk is 2:1000.

c) Ask LMP and preferably perform it in follicular phase.

Advise to continue previous contraception till the procedure( IUCD/ barrier method)

Do Bhcg on the day of surgery to further reduce the risk of pre existing conception. Sterlisation in puerperium carries high risk of failure

Posted by Shilpa A.

 

History & examn: Enquire about her decision & reason  & that she has completed her family & is not under any co-ercion  from anyone or has not had recent stresses in life like break-ups since the regret rate could be higher in such cases & hence she could be advised additional counselling& consider postponing procedure.

Whether she is aware of other contraceptive options ie LARC vasectomy ( options may not have been discussed.) She may not know her partner can have vasectomy. Discuss Mirena LNG IUS with a better pearl index & can be done as an outpatient procedure.

With  regards to consent , ensure that  she has the capacity to consent & understand procedure, since if not it should be referred to the courts.

 Ensure that  she is using  contraception up to the date of operation otherwise procedure should be deferred & done in the next proliferative phase of cycle since possibility of luteal phase pregnancy cannot be ruled out .

 A pregnancy test should be done before the operation to exclude  pre-existing pregnancy but  a negative test does not exclude a luteal-phase pregnancy.

A detailed medical, surgical & obstetric history should be obtained; to note factors ie Obesity, Hypertension, asthma, & cardiac problems which cause additional anaesthetic & surgical risks.

Her previous history of any caesarean sections, previous gynae surgeries, previous PID , endometriosis, appendicectomy which increases the risk of procedure being converted into a laparotomy.

Clinical examination to identify comorbidities  should note any midline scars on the abdomen(risk of bowel injury with laparoscopy higher) , internal examination should note any fixity or restricted mobility of uterus ( suggesting endometriosis)any ovarian masses, fibroids( increases the risks of laparoscopy ,might need other procedure & end up in laparotomy).

 

Regarding lap steri :Other methods of contraception their advantages & disadvantages discussed (LARC, vasectomy).Confirm it is her decision & her family is complete .

 

She must understand that the procedure is permanent, but there is a lifetime failure rate of 1 in 200; & if it fails, then the pregnancy may be ectopic.

It is usually done as a day case surgery. A pregnancy test is done before the operation to exclude any pre-existing pregnancy but a negative test does not exclude luteal-phase pregnancy. Filshie clips or rings are used to occlude the tubes.

 

She should be informed that laparoscopy is quite often associated with bruising and shoulder-tip pain.Other potential problems include failure to gain entry to the abdomen, & injuries to the bowel, bladder or blood vessels are serious but infrequent risks - 3 in every 1000, death occurs  in1 in 12 000

Those who have had  previous abdominal surgery or who are obese, should be informed of the increased  risks of laparoscopy and the chances of needing  laparotomy if there are difficulties with laparoscopy.

They should be reassured that it is not associated with an increased risk of heavier periods when performed after 30 years of age.

 It should be mentioned that reversal is  not funded by the NHS & in good hands 30-40% success rate depending on type of sterilization done.

All discussion should be documented in detail & a leaflet giving the information should be provided.

 

Minimising risk after :

Women at risk are those who have had any unprotected intercourse in the same cycle as the sterilisation. A negative test could provide false reassurance

Even if pregnancy test is negative Luteal-phase pregnancies occur in about 2–3/1000 procedures  when women are sterilised after unknowingly conceiving in the same cycle .

It is important therefore in preoperative counselling, to emphasise the need to continue an effective method of contraception throughout the cycle in which the operation takes place.

If the combined oral pill is used, the current packet should be finished.

If the progestogen-only pill is used, it should be continued until the end of the packet or the next period, whichever occurs earlier.

If a contraceptive patch is used the present patch cycle needs to be  completed.

If the woman has a copper IUCD or LNG-IUS in place, this should be removed at the next period.

 

 

Posted by rimpi D.

Itried sending answer, but some problem.

essay 354 answer Posted by rimpi D.

a) Her reasons for sterilisation should be explored and confirmed that she has completed her family and not making a decision in haste.Her menstrual history with LMP , cycle regularity should be asked to exclude possibility of pregnancy and to schedule her surgery in follicular phase.Her obstetric history with number of children, any previous cesarean section and date of last delivery is enquired. This is important as sterilisation in immediate postpartum period is associated with higher failure rates. also past surgeries can cause laparoscopy difficult .her past medical history like DM, HTN, cardiac problems, for fitness of surgery is elicited. Her previousabdominal or gynecological  surgical history is enquired as it will be associated with higher rates of conversion to laparotomy from laparoscopy.Past and current use of contraceptives is asked to exclude luteal phase pregnancy and advised to continue till next cycle poststerilisation.Her stability of relationship with her partner should be explored to reduce chances of regret later.

BMI, BP is measured. High BMI is associated with failed entry at laparoscopy . Abdominal examination done to locate any previous surgical scar to decide the postion of laparoscopy incision. Also any palpable lump should be excluded before undertaking laparoscopic surgery.bimanual examination for mobility of uterus( restricted in adhesions and endometriosis) or palpable cyst is done.

b)She should be counselled that it is a pertmanent method of sterilisation. reversal is possible but has poor reproductive outcome and higher chances of tubal pregnancy. Reversal surgery is not funded by NHS.The failure rate of 1 in 200 should be clearly informed.Other LARCs for contraception should be informed with their risks and benefits. She should be informed regarding vasectomy of her partner which has low complication and failure rates of 1 in 2000 compared to female sterilisation ( 1 in 200).The procedure of sterilisation is explained to her that it is done under GA . laparoscopic or hysteroscopic sterilisation is possible but the latter still under evaluation. In laparoscopic procedure abdomen is enetred by key hole incisions and fallopian tubes are occluded using clips or rings. It has advantage of day case surgery with short recovery and low morbidity. It is associated with minor common complications like shoulder tip pain or postop pain which can be well controlled using analgesics. It should also be counselled that laparoscopy is associated wth rare but serious risks like bowel and vascular injury( 3 in 1000) and  rarely mortality  of 1 in 12000 cases.The possibility of onversion to laparotomy should also be counselled in case of extensive adhesions , or obesity which is about 1-3/1000 cases.

c) To minimise the risk of pregnancy following sterilisation, the procedure should be scheduled in early follicular phase.pregnancy test should be done on day of surgery though it may miss luteal phase pregnancy. In case of doubt,postpone surgery till next menses.the ongoing contraceptive should be continued till the end of pack in case of horminal pills . IUCD should be removed after the next menstruation to reduce chances of luteal phase pregnancy.During the procedure the fallopian tube should be corectly identified by tracing it to fimbrial ends prior to clip application. diathermy should not be used as associated with high failure rates.During the applicayion of clips , the full thickness of the tube at isthmo-ampoullary junction should be included.sterilisation inimmediate  postpartum period to be avoided if acceptable to the woman as associated with higher failure rates.

answer to 354 Posted by C M.

a) Firstly I would establish her LMP and cycle length as this will inform me of her normal cycle and would aid I discussing contraception around the time of the procedure and may give indication towards ?premature menopause or if she has menorrhagia this could be dealt with by alternative routes. Enquiry about how many children she has and to be sure that she has indeed completed her family is important as this is an irreversible procedure and should be undertaken if the patient is sure about it. I would also enquire about her current method of contraception and what she has used in the past and her reasons behind her request for lap sterilisation as there are other alternatives on the market that are not quite as invasive and not carry the same risks as a general anaesthetic. Importantly is asking if her husband has considered having a vasectomy that has a 1:2000 risk of failure as opposed to a 1:200 from lap steri. Past medical history such as diabetes, previous peritonitis, abdominal surgery are important as they pose risk factors for the laparoscopy whereby an experienced and skilled practitioner will need to be present for the entry of the main trochar – risk of injury to organs. On examination I would get her height and weight to calculate the BMI from a moving and handling perspective and also if she has a BMI of greater that 35 or less that 19 she may require a Hassan’s entry and also an anaesthetic review for the high BMI lady from an anaesthetic point of view. A urine pregnancy test is important to rule out an ongoing pregnancy and palpation of the abdomen to rule out any frank masses is also important and look for previous surgical scars.

 

B) Its important to ensure that she is sure that she has completed her family and that other alternative contraceptive options have been explored ie. Vasectomy risk of failure 1:2000 vrs Lap steri 1:200 risk of failure. The options of either a mirena coil, IUCD, Depo-provera or the implant may be other modes. If she is sure about this then I would explain that the procedure would be a day case procedure which would require a general anaesthetic and would involve making a minimum of 2 small 1inch length holes in her abdomen and a telescope used to aid with placing clips on her fallopian tubes. There is a risk of injury to her bladder (0.3%), bowel, blood vessels (0.6%) , ureters (0,1%). There is also a risk of pain, infection on the wound sites and bleeding and shoulder tip pain post operatively. The failure rate is quoted as 1:200 and this could be from recanalisation or misplaced clips or if they fall off. There is an increased risk of an ectopic pregnancy and if she were to become ammenorheic she should present to her GP. The procedure is permanent and reversal would be very difficult. There is a risk of death 1:12000. The wounds would be closed with either glue or suture and as long as she has voided good volumes she can go home later with no further follow up required.

 

c)  A UPT on the day would have indicated she were not pregnant but unless she was on her first day of her next period she would not have been protected therefore if she was on the COCP I would encourage her to complete the pack till her next period. If she was on the POP she would either need to complete the pack or take the next 7 days and then she would be covered. Advise that if she were to become UPT positive to see her GP asap for an early pregnancy scan to rule out an ectopic

 

essay 354 Posted by Katy V.

 

a) Sterilization should be considered as an irreversible procedure. It is therefore important to establish the reasons behind the woman’s decision and her certainty. Additionally the history and examination should aim to identify factors that might make alternative methods of long acting contraception (LACs) either more suitable or contraindicated. Obstetric history is essential both in terms of the age of her children (greater regret is associated with sterilisations performed within 6 months of the birth of a child or if there are no live children) and the mode of delivery, as previous caesarean sections are associated with anterior abdominal wall adhesions and increased surgical risks at laparoscopy. Social history should also be assessed. Although it is not obligatory, it is preferable that any long-term partner be involved in such a decision and if she were not in a relationship I would suggest she considers reversible methods of LAC. However, copper coils may not be appropriate if she has multiple partners and is at risk of PID.

Whilst there is no evidence that sterilisation increases menstrual problems such as menorrhagia and dysmenorrhoea, women frequently experience a worsening of such symptoms when they stop hormonal contraception after sterilisation. It is therefore important to enquire whether such problems are present or were before commencing hormonal therapies. Additionally, information about current and previous contraceptive choices is important to assess suitability of alternative methods of LAC. A medical history should also be obtained to identify any contraindications to LACs and point towards any additional anaesthetic risks.

Examination should focus on those factors increasing surgical and anaesthetic risks. Thus BMI and BP should be measured and abdominal scars identified.

 

b) Counselling should cover both the risks of the procedure and the suitability of alternative methods of LAC. The discussion should be supported with the provision of written information, both about the procedure and alternatives.

It is important to emphasize that sterilisation is considered an irreversible procedure. Whilst reversal may be possible, it is not available on the NHS and is associated with low success and increased ectopic rates. IVF would be an alternative, but would also not be funded by the NHS for this indication. The risk of a worsening of menstrual symptoms should also be emphasised and alternatives such as the levonorgestrel releasing intrauterine system (LNG-IUS) recommended.

The surgical risks that need to be discussed include a 1/200 risk of failure, with the increased risk of ectopic pregnancy should pregnancy occur. Additionally, laparoscopy is associated with a 3-4/100 risk of major complications such as bowel damage and a considerably higher risk of minor complications including port site bruising and pain. Furthermore, it may not be possible to enter the abdomen and thus either mini-laparotomy will be required or the procedure abandoned. Anaesthetic risks should also be addressed, as whilst it is possible to perform laparoscopic sterilisation under local anaesthetic, this is rarely undertaken in the UK.

The two main alternatives that should be discussed include male sterilization (vasectomy) which has a lower failure rate, is performed under local anaesthetic and is associated with less complications and the LNG-IUS which has a similar failure rate to sterilisation, but doesn’t require an anaesthetic, is immediately reversible and has the potential to reduce mennorhagia/dysmenorrhoea. Copper coils and injectable/implantable progestagens can also be considered.

 

c) In order to minimise the risks of pregnancy following sterilisation, it is firstly important to ensure that the woman is not pregnant at the time of the procedure. Thus, she should be encouraged to continue with contraception until her next period and if she is not in the menstrual/early follicular phase, pregnancy test should be performed. However, there is no place for routine D&C during the procedure. Failure rates can be reduced by ensuring adequate training of surgeons (>30 procedures performed under supervision) and identifying the full length of the fallopian tubes (to distinguish from the round ligament). It should be confirmed that the clips occlude the entire width of the tube and ideally this should be supported with photographic evidence.

Posted by Muthu M.

 

  1. I would like to enquire about her period cycle; how often does it occur, how long does she bleed and any heavy period, pain, inter-menstrual bleed.  This will help us to discuss other options of contraception which also will help in regularizing the cycle.  I would like to know, her last menstrual period to rule out that she is not currently pregnant.  I also want to know, what contraception that she is using currently and whether she has any concern to that and whether she has completed the family.  I want to know the reason that she is considering sterilization and whether she has discussed or considered other options so far and mainly whether she knows about long acting reversible contraception.  I would like to know her previous obstetric history, mainly mode of delivery and any abdominal operations before, which are important when counseling the risks involved in laparoscopic sterilization.  I would enquire about any medical problem and on any long medications, this help me to arrange for her to be assessed by anesthetist before the surgery.  On clinical examination, I would like to check her BMI, and on abdominal and vaginal examination, whether there is any obvious palpable mass which may affect the laparoscopic procedure – such as big fibroid uterus upto the umbilicus, previous scar, where we may have to consider palmar entry or again consider other alternative contraception option.
  2. When I counsel the patient I will inform her about the risks related to 1. Laparoscopic procedure 2. Sterilization and 3. Anesthetic risks.  With regard to laparoscopy, I will inform the risks to bowel, bladder and pelvic vessel injury and also there is a possibility that not able to enter the abdomen through laparoscopic ally and the procedure will not be done.  I will inform her need for laparotomy if any injuries that could occur, which need repair.  With regard to sterilization, I will inform her that it is a permanent procedure and if she wishes to be reversed in future, the success rate is low.  Also inform her about the failure risk, 1:200, and risk of ectopic pregnancy if she falls pregnant.  I also briefly inform her about the anesthetic risk due to this procedure.  I will inform her that it would be a day case procedure, will be done under general anesthesia and she is expected to return home on the same itself unless any complication that would arise during the procedure.  She should come to the hospital after fasting atleast 6hours, and she needs to be picked-up at the end of the procedure as she will be under the influence of drugs.  I would inform her to use whatever contraception that she has been using so far until after the procedure.
  3. While doing the procedure, the filsche clip is applied to whole width of the tube.  Check the tube both front and back to make sure the same.  To make that it is fallopian tube, trace it from the uterine end to the fimbrial end.  Try to apply the clip within 1/3rd distance from the uterine end.  Advise the patient to continue the current contraception.  I would also inform her that she should continue the same even after the procedure until she has her next period.  In case, if she is not using any contraception, I would encourage her to use some kind of contraception which she could be comfortable with or consider abstinence.  I would also do a urine pregnancy test on the day of operation to rule out any possible pregnancy.  I would also enquire about her LMP on admission for the procedure and also enquire about the unprotected intercourse since her period in the current cycle, mainly within last 5days duration, which may be at risk of falling pregnant.  If so, consider cancelling the surgery after counseling the patient or make sure the patient understands the risk and possibility of pregnancy.  
ESSAY--354 Posted by lamia T.

a)She is 37 years old,so in history I will ask her did she completed her family and is there any doubt for a permanent and irreversible method like sterilization.Either she is in a stable relationship we should confirm it because later on she may regret for sterilization or ask for recanalization.

I will take detailed menstrual history-any complaints of menorrhagia or dysmenorrhoea.If she has such complaints she can use long acting reversible contraceptive like LNG-IUS(MIRENA) because it reduce her heavy bleeding.

Her previous mode of deliveries,timing of last delivery everything should be noted properly.Previous history of caesarean section,any abdominal surgery can complicate laparoscopic sterilization procedure.Tubal occlusion should be performed after an appropriate interval following pregnancy. If she requests tubal occlusion postpartum or following abortion should be made aware of the increased regret rate and the possible increased failure rate.

Contraceptive history is very important in this case.Either she used any contraceptive before or continuing we should ascertain that.Because luteal phase pregnancy we can avoid by continuing contraceptive upto next cycle.Her past medical history also should be asked for because of risk for anaesthesia.Although local anaesthesia can also be used .

In physical examination her BMI should be calculated.Obesity could be the reason of failure.Abdominal mass or pelvic mass should be excluded by physical examination because it may change the plan towards hysterectomy.

b)Before planning for sterilization procedure she should be informed about other alternatives like vasectomy for her partner which is associated with less complication.She should be informed about long acting reversible contraceptives also.Finally if decided for sterilization then she should know the advantages and disadvantages of the procedure.It is a permanent procedure so she should be certain of her request.

She should be informed of other procedure for sterilisation like hysteroscopic or minilaparotomy.Laparoscopic procedure is associated with less minor morbidity in comparison with minilaparotomy.Laparoscopic sterilization using filshie clip are current recommended practice.Usually general anaesthesia is used so risks of it should be explained to her.But local anaesthesia can also be used .The procedure is conducted as a day case.Topical application of local anaesthetic if mechanical clips are used can reduce post operative pain.

Serious risks of laparoscopy like failure to gain entry,visceral injury,uterine perforation everything should be explained to her.Frequent risk like shoulder tip pain,abdominal discomfort also to be informed.We should explain that laparotomy may be needed to repair injury or to complete the sterilization.

We have discuss the failure rate of sterilization 1:200 and the risk of ectopic pregnancy if sterilization fails.Risk of death is 1:12000.She should also be informed that reversal procedure is not funded by NHS and success rate is 70%.

The counseling should be documented and written information and leaflets should be given to her.

c)Cause of failure of sterilization could be failure to exclude pregnancy like luteal phase pregnancy.So pregnancy test should be done .Although it cannot exclude luteal phase pregnancy.So if pregnancy cannot be excluded she can be advised to come next follicular period.She should use effective contraception until next period.If she is using LNG-IUS/IUCD it can be removed during next menstrual period.

Another reason  for failure is incorrect application of Filshie clip during the procedure.So proper training is needed before conducting the procedure.All equipment should be tested and well maintained.

Tubal recanalisation is also a cause of failure.Hulka clips ,diathermy should be avoided as these are associated with high failure.Filshe clips should be applied 1-2cm from the cornua, at right angles, encasing the full width of the tubes.

H H XXX Posted by H H.

Will ask regarding her parity and last delivery(sterilisation through minilaparotomy if she is early post partum). Will ask of her LMP and regularity of her period ,to exclude being pregnant. Will ask about type of contraception she is using ,this should be continued through and after the procedure to avoid luteal phase pregnancies. Will ask if she has any medical condition as cardiac or respiratory disease that can be worsened should the patient have general anesthesia or pneumoperitoneum. Will ask of any previous history of venous thrombosis to take measures for thromboprophylaxis. Will ask if she had any previous abdominal surgery and its site ,as this this can alter my entery site by the verres needle(palmer point) or change my intraperitoneal access to an open technique(Hason).

Will ask if she is taking medications that would interact with anesethtic drugs eg opiates,or if she is a smoker . Would ask her of her partner and his support for her decision.

Clinical examination ,BMI , morbid obesity >40 ,will need care on manual handling,inform operating theatre , open technique for intraperitoneal access and thromboprophylaxis. Thin patient will also need open technique of intrperitoneal access. Abdominal examination for surgical scar specially midline incision,alter point of entery. Abdominal mass eg splenomegaly , avoid using palmer point of entery.

B) Will ask her for the reason why she wants a sterilisation.Will make sure she is not forced to do so spcially if she is an immigrant.

Will tell her about the implication of the procedure and that it is meant to be a permenant procedure ,reversal carries risks and not covered by NHS. Will explain the procedure ,that it is a key hole surgery where clips are applied to the tubes to occlude them. Will tell her that failure rate is 1 to 200 procedure over a life time and that pregnancy should it occur is usually an ectopic.

Will tell her that if she was taking the pills as contraception, she will find her periods heavier, this is due to stopping the pills and not due to the procedure. Will counsell her regarding the serious risks of laparoscopy, bowel and vascular injuries <1 per1000 procedures, uterine perforation 1 in 1000,and risk of death 1 in 20 000 procedures. Frequent risks,shoulder pain and wound discomfort. Will tell her about additional procedures that will be necessary in case of injury and might have a colostomy.

I Will tell her that the procedure might be completed through a minilaparotomy in case of failure to access the abdomen through the laparoscope.

Will councell her about the type of anesthesia,and that usually it is general,and tell her about its problems(difficulty in intubation ,aspiration).

Will tell her about long acting reversible alternative methods of contraception , Mirena , for 5 years, side effects,irregular bleeding 1st 3months,difficulty in application,effective contraception. Nexplanon,3 years,skill for application,hormonal contraceptive, systemic side effects of progesterone as bloating,but is effective contraceptive. Depo proverb, for 3 months ,irregular bleeding and bloating. Will discuss vasectomy as an alternative.

C) First measure to minimise this is to do it after her menstruation provided that she has a regular period. I would avoid luteal phase sterilisation ,unless that the patient is using an effective method of contraception ,which she should continue using it during the procedure and after it till she gets her period. Should the patient be not having her period eg with Mirena,the coil should not be removed during the procedure of sterilisation and removed 7 days after it.

I should know that a negative pregnancy test will not exclude her getting pregnant after the procedure.

During the procedure I should visualise the tube and confirm this by seeing the fiimbriated end, then will apply the Filshi clip perpendicular to the tube at 1-2 cm from the cornue,including the whole width of the tube. Will visualise the tube again with the clip on.Will video the procedure as a future record.

 

 

Laparoscopic sterilisation Posted by Bindu R.

a]   Sterilisation is  a permanent and irreversible  method of contraception  so  ensure that the woman is  certain of her request and her family is complete.If there  are any concerns about capacity to provide consent  then   refer to court.

Proper history must be elicited.

Get obstetric history regarding  parity as care to br takrn in nulliparous  woman requesting sterilisation.History of last child birth as  sterilisation  post partum or post termination of pregnancy  is associated with  increased regret and  failure rate.h/o mode of delivery because previous abdominal surgeries   might have intraabdominal adhesions and potentially difficult laparoscopic surgery  with more complications  and so entry technique have to be modified accordingly.

Get  detailed menstrual history  .Elicit her LMP and eclude any on going pregnancy by pregnancy test  but negative pregnancy test does not exclude luteal phase pregnancy.

Gynaecological history of menorrhagia or other  significant  pelvic pathology  makes options like LNG-IUS or hysterectomy more appropriate.

Contraceptive history-Ensure  she is using proper contraception until date of procedure and advice her to continue till her next  periods after sterilisation.

Previous surgical history to be elicited  to plan the laparoscopic surgery.

Medical history to  be  elicited regarding  any chronic illness,HIV,hypertension,diabetes,Sickle cell disease  etc to get fitness for anaesthesia and plan surgery.

Check her BMI -Risk of  laparoscopic  surgery  especially during entry   is high in morbidly obese and underweight  woman.

Support verbal councelling with appropriate written  information.

B }   Laparoscopic tubal occlusion using Filshie clips is  currently recommended.This procedure is intended to be  permanent  ,however  success rate of reversal is  31-92 %.Treatment  like reversal,IVF,ICSI is not available  in NHS.

She shouls be councelled regarding the  risk of ectopic pregnancy rate of 0-7 %.She should be informed that  the failure rate  of tubal ligation is  1 :200 life time { vaectomy  1: 2000 ].

Laparoscopic strerisation is usually done under GA ,local anaesthesia is  alternative.Can be done as a day case.39 % of  deaths from female sterilisation  related to anaesthetic complications.Procedure sholud be done only in   sites where  facilities  to perform laparotomy is available.

Councel her about risk of laparoscopy including  visceral injury,bowel injury,vessel injury,failure to gain entry into abdomen and possibility of laparotomy   in case of visceral injury or minilap to complete the sterilisation.

Tubal sterilisation is associated with  increased  hysterectomy dates in the future-limited data on young woman.

She should be councelled to use  contraception until next  periods.

Provide her with written information and further appointment if needed.It is good practice to  involve both partners in decision making.Ensure proper documentation  of the consultation.

C]   Main cause of failed sterilisation   is preexisting  pregnancy due to luteal phase sterilisation,incorrect application of Filshie clips and recanalisation.

Take  her LMP history before procedure.Avoid luteal phase sterilisation.Negative pregnancy test does not exclude pregnancy.

Effective contraception   to be continued  until  next menstrual   period after sterilisation.If using IUD then remove it during the procedure and  avoid unprotected sexual intercourse 7 days after the procedure.

All the instruments should be tested and maintained.

Procedure should be done by trained surgeons or supervised  appropriately.

Filshie clips should be applied 1-2 cm  from the cornua  at right angles enclosing the full width of the tube and this should be documented.Hulka clips and diathermy  should be avoided as failure rates are high.

Posted by K9 S.

A healthy 37 year old woman has been referred to the gynaecology clinic because she wishes to be sterilised. (a) Discuss and justify the information you will obtain from the history and clinical examination [7 marks]. (b) Describe your counselling with specific reference to laparoscopic sterilisation [9 marks]. (c) Which measures will you take to minimise the risk of pregnancy following sterilisation? [4 marks]

A) I would assure that she understands the implication of the procedure in terms of failure rate and probability of regret in the future as sterilisation procedures are not meant to be reversible.

I would confirm that she's had discussed alternatives which can be at least as effective and so far less invasive( Mirena coil).  or male sterilisation( vasectomy). Confirm the reason behind asking for surgical sterilisation( has had tried other methods and failed?). Mirena coil faliure rate 1/1000, Vasectomy 1/2000 in comparison to tubal sterilisation 1/200

I would take a full menstrual history,LMP and possibility of being pregnant as the procedure preferably to be done in folicular phase. pattern of periods and how heavy they are, pelvic pain and presuure symptoms suggesting a pelvic mass.

If she has got childern, how many and the mod of delivery as previous C/S may render laparoscopic sterilisation difficult. Presence of previous comorbidities such as endometriosis and previous STI also can form adhesions band and make tubla identification difficult and add on risks of procedure.

Previous abdominal surgeries and kind of incision, pervious bowel inflamatory disease or peritonintis all make sugical sterilisation difficult and higher risk of complications.

From examination I would ascertain her fitness for surgery, BMI as high  BMI leads to higher failure of cavity entry and higher complications rate( including VTE and infection). Adbominal ex. for any palpable masses at risk of injury if laparoscopy choosen.  Vaginal examination directed by history if heavy periods or pressure symptoms to  exclude a pelvic mass and to recommend USS if necessary.

b)  a laparoscopy is a key hole procedure, the camera is introduced in the abdomen(tummy) through a 1 cm incision in the belly bottom. a need for further one or 2 small cuts of 5 mm each in the sides to facilitate applying clips on the tubes so the sterilisation achieved. The tummy will be insuflated with gas to creat an operative field for easy access and visualisation of organs. The procedure is of 30-45 minutes, usually quick recovery with the ability to be discharged several hours  later.

It is generally safe procedure, done by trained Dr or a trainee under direct supervision. Complications include faliure to enter the cavity esp. if high BMI. first two steps are "blind" so there is a risk of injury to major vessels ( 2/1000) or bowel injury (3/1000). 

Faliure rate of the procedure is 1 in 200, the highest risk is in the first year usualyy not operator dependent and maybe caused by microcanalisation.

Should she be pregnant in the future she has to contact helath services immediately to arrange for USS for preg. location as high risk of ectopic.

  c) I would advise her that pregnancy can still occur if  the procedure is done later in the menstrual cycle. If she is on COCP I would advise to continue until next period. If she has IUCD fitted then to be kept until next period. To use barrier contraception if not on any. DC not recommended. 

 

essay 354 Posted by Nabila A.

 

Enquiry about her obstetric history will reveal parity as well as the mode of delivery /deliveries .

A detailed menstrual history including  date of the last menstrual period ,regularity of the periods,any complaints of menorrhagia/intermenstrual bleeding or associated dysmenorrhea/dyspareunia to find out any problem requiring additional treatment  which  can modify the decision to undertake LNG-IUS or hysterectomy preferable.

History of any gynaecological procedure/surgery done in the past.Cervical smear  should be enquired for.A  detailed sexual history taken to know about the present relationship with the partner,any coital difficulties.A sensitive enquiry about the no. of partners or recent change of partner also to find out the risk for sexually transmitted diseases.Current method of contraception is asked for ,also any other method used in the pastAny history of unprotected sexual intercourse and likelihood of her being pregnant.Enquiry about the stability of the relationship and reasons for her decision to undertake sterilization.

Medical risk factors ….chronic hypertension,diabete,ischemic heart disease  should be asked for to ensure her medical fitness to undergo general anaesthesia.

General physical examination  include her physical and emotional wellbeing, BMI  which will help in thedecision to  proceed to laproscopy or if more  to advise her about alternatives in case chances of difficulties  during laproscopy Abdominal examination to rule out any fibroid/mass .Vaginal speculum examination  to visualize  the cervix …ectropian,polyp if any,smear taken in case it is due.Bimanual examination to asses the size of uterus ,position ,mobility,adnexal mass or tenderness,any nodularity of the uterosacral ligaments to find out any pelvic pathology necessitating treatment.A pelvic ultrasound will help identify any uterine or adnexal mass if pelvic examination inconclusive or difficult due topatients habitus.

A pregnancy test will be mandatory ,however it will not exclude the luteal phase pregnancies.

Ideally  couselling for sterilization should be done wiyh the couple together although it is not a legal requirement.Ensure patient is competent to give consent for sterilization.Make sure she understands that sterilization is  a permanent procedure in which the tubes are  blocked  which can  be reverse d  by surgical recanalization .the reversal procedure as well as the IVF required will not be provided  by NHS.Following reversal, intrauterine pregnanacy rates  ARE 31-92% AND ECTOPIC PREGNANCY  0-7%.

Sterlization is done by blocking the fallopian tubes during  as a day case procedure  under general anaesthesia  which is not  without risk . In laproscopic sterilization,  the camera is inserted into the abdominal cavity to visualize the organs.The tubes can be blocked by different methods.these are cut and ligated with absorbable sutures.clips or rings can be used  which are preferred as there is less failure rate with clips ..The risk of boewl injury is 0.4-3/1000 and vascular surgery 0.2-1/1000 laproscopiesIf previous surgery or overweight there can be  risks  f failure of entry  or vascular /bowel injury.In that situation laparotomy may be required ..risk of laparotomy is 0.4- 3.1/1000 and risk of death is 1/12,000.

Failure of sterilization can occur which is 1 in 200 .In case of failure ther is increased risk of ectopic pregnancy 4-76% .If she has any doubt that she is pregnant..onset of severe abdominal pain ,she should seek medical help immediately.There is no increased risk of menorrhagia with tubal ligation .She should use effective contraception till the procedure and till the next cycle .Sterlization  of the partner has got less risks than laproscopic tubal ligation. As well as low failure rate 1 in 2000 .Alternatively  there are long acting reversiible contraceptives which  include intrauterine copper devices which have failure rate of 1.9% after 12 years ,LNG;IUS which have  afailure  rate of 1.2% after 5 years .these are reversible..fertility is not delayed following discontinuation ..can be used for 10 years and 5 years respectively ..dont need any follow ups .verbal information is supplemented with written information.

To minimize the risk of pregnancy following sterilization..make sure she will use an effective contraception till the next period.If there is any difficulty in access to the tubes or procedure during tne surgery ..inform the patient ,advise to use effective contraception and hysterosalpingogram done to find the patency.

rest of the answer 354 Posted by Nabila A.

In case of doubt emergency contraception in the form of copper IUD or uliprestol  single dose  30 mg can be offered.Routine luteal phase  curettege is not recommended.

Essay 354 Posted by Samira  K.

-In history we will explore the reason of her request as request following break of relationship or Pressure from her partner or other relatives will lead to regret.Her menstrual history relating Last menstrual period(LMP) and any irregular periods should be asked to make sure she is not pregnant and in cases of doubt pregnancy test can be performed.Ask about menstrual flow as some women relate sterilisation with menorrhgia. her contraceptive history should be asked as continuation of her current method will be required to increase success.her relationship with her husband is important as unstable relationship might lead to regret.Her obstetric history regarding no.of kids as nulliparas regret more later on.Age of her last child as immediate post partum or post abortion request will lead to increase failure and regret.Her past surgical history or previous pelvic inflammatory disease(PID) should be asked as abdominal surgeries or PID can cause adhesions and increase morbidity during laproscopy.

In examination general examination to see if she anxious or under pressure.Her BMI as obesity increases the risk of surgery.Abdominal examination to find any masses or Scars of previuos surgery .On speculum examintion look if cervix looks normal and we take smear at the same time if not taken recently as many women relate cancers with sterilization which is just a myth.Uterine size,position,mobility,adnexal fullness to look for any undetected genital abnormality.

b-Counselling involves risks and benefits of sterilization.It is found to decrease risk of ovarian cancer in women with BRACA 1 mutations.Overall there is no specific health benefits from sterilisation. but it will not increase risk of cancer,menorrhagia,dysmenorrhea or irregular bleeding.there will be no effect on libido.women should be encouraged to use barrier methods as this procedure will not protect from sexually transmitted diseases.Laproscopic sterilisation involves risk of general anaesthesia which can be reduced by doing it under local anaesthesia.Laproscopy itself carries risk of bowl damage which is rare i.e.0.4 in 1000 and major vessel damage 0.2 in 1000.which might lead to laprotomy .there is one third risk of ectopic if pregnancy occurs after sterilisation.she should be informed that it is an irreversible method but reversal is possible with success rate of 30-70% but pregnancy rate of 50% only .She should be aware that reversals and artificial fertilisation is not covered by NHS.10 years Failure rate of laproscopic sterlisation depending on the type of occlusion device used is 2-3 per 1000.Women should be informed that male sterelisation or vasectomy is less expensive with less risks and less failur rate.Other methods of long acting reversible contraception(LARC)should be discussed likecopper intrauterine contraceptive devices(IUCD) with failure rate of 0.5 in 100 and LNG.IUS with failure rate of 1 in 1000.and injectables depot medroxyprogestrone acetate(MPA )and subdermal implants with failure rate of approximately 1 in 1000.All of them are reversible in case you change your mind and they are easy to apply not requiring anaesthesia or laproscopy with all their risks .Women should be informed that all of them have their own disadvantages like Mirena causes irregular bleeding for around 6 months and injectables (MPA)causes weight gain and decrease in bone mineral density .Subdermal implants also can cause irregular bleeding and sometimes removal needs to be done under anaesthesia.counselling should be supported by accurate,impartial printed or recorded information with translation if needed and possible

c-Risks of pregnancy can be reduced by performing procedure in follicular phase and if there is any doubt from history or examination to perform pregnancy test.she should be advised to use her current contraception until the day of the procedure and until next mensturation.Immediate post partum or post abortion procedures should be avoided.Age less then 30 years leads to increase failure rate.In C-section modified pomeroy technique use will increase success rate.Laproscopically type of occlusion method like filsie clips increase the success rate.

sterlization Posted by HAnaa B.

PATIENT ‘S  DETAILED HISTORY ABOUT CURRENT CONTRACEPTION AND WHY SHE IS WISHING TO CHANGE THE METHOD, ANY CONCERNS ABOUT COMPLICATIONS OR SIDE EFFECTS FROM HER PREVIOUS METHOD , HOW RELIABLE IS AHE WITH HER MOTHOD ITS WAY OF TAKING IT.

HER PARITY AND WETHER SHE COMPLICATED HER FAMILY OR NOW ,Any social cause that lead her to cut down her fertility.

WHY OF HER PREVIOUS DELIVARIES, NORMAL OR Cs , it may affect the surgical technique latter one . her menstruation timing , LMP , frequency ,regularity heavy or light., her sexual activity whether she is in a stable relation or now , to decrease the risk of regret if she will seek  another partner.

If she has enough information about all types of contraception specially vasectomy, simple procedure ,less risk and effective after 3 month.

Gynecological history, especially operations, prolapsed or previous pelvic operation.

Previous medical history will be affected the surgery like asthma,

Examination my reveal High BMI more than 40, which is dangerous for operation and advice for another method, is more reliable.

B

Patient should be given all the information related to laparoscopic sterilization after full counseling and consent for the procedure using information leaflet and she should be given enough time before signing the consent.

She should know that laparoscopic sterilization can be done  under general anesthesia, by competent surgeon where we will inject gas in her Tammy to distend her abdomen then felshi clips is applied to the whole entire width of her fallopian tunes 1-2 cm from the corneal end of the tube .

She may experience pain and bruises after the operation with gaseous distension and shoulder tip pain , NSAI is used for few days , the operation  can be done as a day case procedure she can go home same day, she should know that there is risk of injury to the bowel and the bladder which is minimal , and also risk of death from the procedure 1/12000.failure to introduce the scope will carry the risk of mini laprotomy at the bikini line.

C

Pregnancy test should be done before the operation, although it can be done at any time of the cycle but preferably in the follicular phase when we are sure of no missed luteal pregnancy ,

Her concurrent method of contraception should be continuously used until her next cycle. Either OCP , patches, rings or IUCD.

Diathermy method during tubal surgery is not used as it increases risk of canalization and failure.

Hulda ring is not used as it slips from the tube.  

Essay: lap steri Posted by Katie  C.

A.  Sterilisation is considered a permanent and irrevirsable method of contraception.  The history and examination should cover reasons for requesting this and suitability for procedure.   Detailed gynaecological history should include LMP, cycle length, any menorrhagia, dysmennorhoea, IMB or PCB; abnormalities may indicate underlying pathology, which may respond better to alternative contraception such as IUS for menorrhagia.  This also enables timing of procedure to avoid luteal phase, when it may be difficult to exclude pregnancy.  Obstetric history including gravida, parity, mode of delivery, outcome and any complications with previous pregnancys.  Previous c/sections may cause scar tissue which could make laparoscopy difficult.  If pregnancy was recent and had a poor outcome this may be associated with regret if a hasty decision is taken to be sterilised.  However if pregnancy was complicated by problems such as severe preeeclampsia it may be safer for the patient to undergo sterilisation rather than risk a further pregnancy.  Previous contraception use should be discussed as this will inform discussion around alternatives to sterilisation such as LARC methods.  Medical history of comorbidities such as heart disease, diabetes, asthma, which may affect anaesthesia and recovery from procedure should be sort.  Surgical history specifically on the abdomen and pelvis will allow assessment of scar tissue and potential technical difficulty.  Social history  including smoking and alcohol use as these may also affect anaesthesia and wound healing post operatively.
   General examination including HR, BP and BMI to assess suitability for anaesthesia.   A high BMI is relevant as it may cause technical difficulty with entry into the abdomen resulting in a failed procedure and is also an anaesthetic problem.  Pelvic examination to rule out other pathology such as fibroids, which may respond better toalternate treatment e.g. hysterectomy and to assess postion, mobility of uterus.  A fixed retroverted uterus may indicate endometriosis and cause a technically difficult procedure.

 

B.  For procedures permantley affecting fertility it is a good idea to include both partners, although this is not a legal requirement.  It should be emphasised that this is considered permanent and irrevirsable and would preclude any future fertility treatment on the NHS i.e IVF.

  It is important to discuss alternatives including no treatment and LARC methods; all of which have lower failure rates than sterilisation.  Implanon is a small rod placed under the skin by the bicep, which releases progestogen, lasting 3 years with a failure rate of less than 1/1000.  The copper IUD lasts 10 years and has a failure rate of less than 1/1000 and the Mirena IUS lasts 5 years, with the same failure rate and the additional benefit of reduction in mean blood loss in 90% of women with 20% experiencing complete amenorrhoea.  Male sterilisaiton should be mentioned as this can be done without a general anaesthetic, has the lowest failure rate of 1/2000 and has minimal risks.  There is no association with testicular cancer or impotence but a small risk of prolonged testicular pain.

  The procedure should be explained; laparoscopic sterilisation is usually done as a day case under general anaesthetic.  A small cut is made in the umbilicus and gas passed via a small needle to inflate the abdomen, this allows a camera to then be placed inside to visualise the pelvis.  A second small cut will be made just above the pubic hair line to allow a second port to be placed to enable the clips to be placed on the tubes under vision.  The gas will be released after the clips are placed and a few dissolvable sutures placed in the cuts.  All procedures carry risk and these can be divided into frequent risks such as bruising around the port sites and shoulder tip pain due to irritation of the diaphagm from gas or fluid and serious risks including a 1/200 risk of failure.  If the procedure does fail and pregnancy ensues there is an increased risk that this will be ectopic (not in the womb), although this risk remains lower than the risk of ectopic in a non sterilised fertile women.  There is a 3/1000 risk of damage to bladder, bowel, ureters and blood vessels and a risk of death of 1/12000, although recent evidence suggests this is probabley lower.  Failure to gain entry to the abdomen and need for mini lapartomy should be mentioned.  Additional procedures that may be needed include laparotomy and repair to bowel, bladder, ureters and blood vessels.  An information leaflet detailing the procedure and risks should be provided.

c.  Pre procedure contraception should be discussed and ideally a reliable method continued until the next menstrual period following the procedure.  If no contraception or natural methods are being employed the procedure should be scheduled to avoid the luteal phase, when it is difficult to exclude pregnancy.  Regardless of contraception a urinary pregnancy test should be done on the day of the procedure.  For women on the pill they should continue taking it until the end of the packet.  For those using a coil this should be left in situ until the next menstrual cycle and then removed. 

If the procedure is technically difficult and there is any doubt that the clips have been correctly placed a HSG should be done to confirm tubal occlusion prior to ceasing contraception.

Ans 354 Posted by Ranu R.

a) The menstrual history of this lady is obtained in details. LMP, cycle length and regularity will help to exclude pregnancy at the time of presentation & schedule sterilisation. Presence of menorrhagia suggests that LNG-IUS may be an acceptable alternative for her. The history of previous and current contraception is noted. Any problems with the contraceptives used, compliance and failures, if any should be asked about. Obstetric history is required which includes number of children, mode of deliveries, timing of last delivery and abortions, if any. Women requesting sterilisation post partum or following abortion have increased regret rate and possibly increased failure rate. Women with few or no children are also at a higher risk of regretting their decision later. Her current relationship status should be enquired sensitively as women who are not in a relationship or in a crisis in relationship have higher rates of regret. Coercion by partner or family member should be excluded. Past history of any previous abdominal or pelvic surgery increases the risk of having a laparotomy. Gynaecological history may reveal presence of fibroids or prolapse & hysterectomy may be a better option in such situation. Previous PID may cause difficulty in laparoscopic procedure. It should be confirmed that she is certain about her family completion and does not wish to conceive in future.

Examination of this lady should include calculation of BMI as obesity poses difficulty in laparoscopic approach. The abdomen should be inspected for any scars and palpated for any mass, as this may cause difficulty in laparoscopy.

 

 

b) While counselling this lady, the reason for her request for sterilisation should be explored and it is to be emphasised that the procedure is permanent and reversal is difficult. NHS rarely pays for reversal procedures or further fertility procedures. She should be informed about the wide variety of long term reversible contraceptives available. This should include information on advantages, disadvantages and relative failure rate of each method. Both vasectomy and tubal occlusion should be discussed and she should be informed that vasectomy carries a lower rate of failure and the procedure carries less risk. If possible, the couple should be counselled together before making an informed choice.

She should be informed that female sterilisation is usually done by ‘laparoscopic tubal ligation’, which means her tubes are blocked or cut during the procedure using a small telescope put into the abdomen through two small cuts. The lifetime failure rate of this procedure is 1 in 200. If the procedure fails, the resulting pregnancy might be an ectopic and she should seek medical advice if she has abnormal abdominal pain and vaginal bleeding. Injury to bladder, bowel and blood vessels are rare complications and can be repaired during the procedure. Failure to gain entry into the abdomen, difficulty in identifying the anatomical structures or visceral injury may require laparotomy. Bruising and shoulder tip pain occur frequently after the procedure. The lady should be advised to use effective contraception till the next period after sterilisation. This ensures that she is not pregnant while the procedure is done. She is reassured that the procedure is not associated with heavier or irregular periods. She should also be aware that sterilisation does not provide any protection against STIs.

All verbal counselling should be supported by written or recorded information to take home and read or listen prior to surgery. Appropriate counselling and valid consent should be documented.

 

c) To minimise the risk of pregnancy following sterilisation, the surgery should be scheduled during the follicular phase of the cycle, if possible.  Use of effective contraception must be ensured till the next period after sterilisation. Surgeon performing the procedure should be adequately trained or trainee under supervision. The equipments used must be checked and maintained in good condition. Bipolar diathermy and spring clips are associated with higher failure rates and hence not recommended. A pregnancy test prior to surgery may exclude pre-existing pregnancy, but luteal phase pregnancy goes undetected. 

HL Posted by holly L.

 

a)Sterilisation is a permanent and potentially non reversible form of contraceptive therefore it would be important to ascertain how many children she has and whether she is certain that her family is complete. Her current relationship would also be important as would the timing of her last delivery. All these factors need to be explored to reduce the risk of future regret.

I would enquire regarding previous and current contraception and if she had she considered alternatives such as LARCS. I would take a menstrual history; if heavy periods a mirena may be a more suitable option then sterilisation as it may reduce her menstrual flow. If she is currently using a hormonal method I would advise her that following cessation her normal cycle would resume which if heavy may not be desirable. I would also ask if her and her partner had considered vasectomy which is associated with a lower failure rate and less procedure related risks.

I would clarify when was her LMP, this is important in terms of timing of the operation. I would also make sure that she is using effective contraception until the operation date to ensure that she would not be pregnant prior to the procedure.

I would enquire about previous pelvic or abdo surgery, previous PID or endometriosis as these would make surgery more difficult. Intra-abdominal adhesions would make a laparoscopic procedure more challenging.

As a sterilisation is a surgical procedure a clinical examination would assess her BMI, assess her abdo to see if any scars, or masses.

b) I would explain that sterilisation is permanent and non reversible on the NHS. There is a 1 in 200 lifetime failure rate and if a pregnancy did occur there is a risk that it may be an ectopic pregnancy. I ensure that the patient was aware of alternatives including LARCS and discuss the pro’s and con’s of these methods. I would also explore whether her and her partner had considered a vasectomy.

 I would explain that the timing of the operation needs to be planned in relation to her cycle and that she needs to use effective contraception until the operation date to reduce the risk of pregnancy. She will be informed that a laparoscopic sterilisation carries less risks and has a quicker recovery time than a mini laparotomy. It can also be performed as a daycase under GA. I would explain both the serious risks associated with laparoscopy (bowel, vascular injury, risk of laparotomy) as well as frequent (shoulder tip pain and abdo discomfort).

Her cycle following the procedure shouldn’t be any heavy unless she was previously using hormonal contraception.

She would understand that in the future if she changed her mind the clips could be removed and attempts made to recannalise her tubes or IVF would be possible. This would however be unlikely to be provided on the NHS.

Verbal counselling would be supported by written information regarding the procedure.

c)Pregnancy following sterilisation may occur due to a luteal phase pregnancy.  Scheduling the procedure during early follicular stage of menstrual cycle and using effective contraception prior to the procedure can reduce this risk.  A pregnancy test should be done on day of surgery though it may miss a luteal phase pregnancy. If there is any doubt the surgery should be postponed until the next menses with ongoing contraception. An IUCD should be removed after the next menstruation to reduce chances of luteal phase pregnancy.

During the procedure incorrect application of Filshie clips ie on the round ligament would clearly result in failure. Adequate training and correct identifaction of the fallopian tubes by identifying the fimbrial ends and placing clip over the full thickness of the tube reduces this risk. Photographical evidence can be taken and put in the notes if there was to be any future dispute. Recannualisation is more common following bipolar therefore Filshie clips are recommended in laparoscopic sterilisation. Sterilisation immediately postpartum is associated with higher failure rates. If there is any doubt regarding tubal patency a HSG should be considered.

Essay 354 BTL Posted by Dr Dyslexia V.

A healthy 37 year old woman has been referred to the gynaecology clinic because she wishes to be sterilised. (a) Discuss and justify the information you will obtain from the history and clinical examination [7 marks]. (b) Describe your counselling with specific reference to laparoscopic sterilisation [9 marks]. (c) Which measures will you take to minimise the risk of pregnancy following sterilisation? [4 marks]

a)      I will enquire her understanding of the procedure which is a irreversible form of contraception. I will enquire about her last menstrual period, her cycle regularity, presence LNG IUS such as MIRENA. Her last unprotected sexual intercourse in relation to her last menstrual period is also take to rule out any pregnancy. Her contraceptive history such as contraceptive failure, non compliance or side effects should be asked as well. Her past pregnancy , mode of delivery , and outcome is important as recent post partum sterilisation increase risk of failure and regret. Past surgical history such as previous laparotomy increases the risk of adhesion and injury during procedure. Her past history for STD or pelvic inflammatory disease is also taken to assess risk of adhesion. I will enquire her current relationship if it is a stable relationship and the possibility of vasectomy with a lower failure and complication rate have been discussed. Examination should include body mass index to assess for risk of obesity and her blood pressure for hypertension. Abdominal examination done to assess presence of any mass or scars which could complicate the procedure. A pelvic examination is done to assess mobility of the uterus for presence of adhesion or adenexal mass.

b)      I would counsel that she will undergo laparoscopic sterilisation which is a irreversible form of contraception and reversal of the procedure if considered is not funded by the NHS. The intended benefits are to not get pregnant. The risk of failure of the procedure of 1: 200 in a life time. I would inform of other alternatives such as long acting reversible contraception which has similiarly efficacious as sterilisation and vasectomy which has lower failure rate about 1:2000. Explain the procedure which would be done under general anesthesia and it usually requires the use of two small incision in the abdomen in the umbilicus and suprapubic region measuring about 5mm in size. Occasionally it could be also placed under the left hypochondrial region  in difficult cases. The procedure is usually done as a day care procedure and would be to return home on the same day. The frequent risk include pain at op site and bruising and shoulder tip pain. Serious risk include injury to bowel, bladder and vessel which is about 3: 1000. There is also risk of unable gain entry and conversion to laparotomy to repair any injury if occurred during the procedure which is rare. There is a also small risk of incicisonal hernia at operative site. Written information in regard to the procedure and patient information leaflets should be given to the patient.

c)       I would ask to continue her contraception of she is on oral contraceptive than to continue till she finishes the pack after the operation or if she is on IUCD then to remove it on her next menses. I would advice abstinence or barrier method if no contraceptive device used from her period of last menstrual period till her next menses after procedure. A urine pregnancy test could be done to on the day of operation to rule out pregnancy , however it could not exclude luteal phase pregnancy. The use of filshe clip done by a trained personnel at the isthmus of the fallopian tube at right angle with evidence of photograph post application would be important. Avoidance of the use of diathermy or hulka clips also reduces the risk of failure. Educating her the risk of failure and to check for pregnancy after a missed period would beneficial.

Posted by Mythli B.

 

The patient is enquired about her current partner and relationship and sexual frequency. If she is not contemplating a long-term association, she is advised to adopted temporary methods. The reasons for her wishing for a permanent method is enquired as patients may be under the impression that Lap sterilization may be a cure for her other gynaec conditions. She is also informed that sterilization does not protect against sexually transmitted diseases and that she must use barrier contraception even later. Her knowledge about the availability and usage of other methods of contraception, especially the active contraceptives-the cu-T and LNG-IUS (Mirena) is probed and she is explained about their advantages. Obstetric history with reference to the mode of delivery and any other surgery like for ectopic or any other condition is asked as previous abdominal surgeries increase the risk of Laparoscopy related injuries. Her last menstrual period and cycle lengths are enquired because it is important to exclude the possibility of pregnancy before sterilization. Associated gynaecologic symptoms like menorrhagia, dymenorrhoea/ dypareunia, dyschezia, pelvic pain are asked for because a co-existent pathology may necessitate a more definitive surgery like hysterectomy than a lap sterilization. She is asked about her medical history (Diabetes, hypertension, asthma, cardiac conditions may make her a high risk for anaesthesia) and if she is on any medication or drugs.

Her Bp and body mass index are measured (obesity increases anesthetic and surgical risks for laparoscopy) Abdomen is examined for scars, mass, organomegaly (spleen especially because if a Palmer’s entry approach is needed) tenderness and the thickness of fat is noted. Vaginal examination is done to assess the size, position and tenderness of the uterus and adnexae if palpable. It is also important to assess the mobility as easily manoeverable organs reduce the operative time.  Nodularity of uterosactrals or in the pouch of Douglas indicates possible endometriosis and pelvic adhesions. Her pulmonary and  cardiac status is assessed.

The patient is preferable seen along with her partner. She is explained that laparoscopic sterilization is dome under general anesthesia with two-three small incisions at the umbilicus and on the abdomen through which scopes are inserted and her tubes are banded. Lap sterilization is generally safe and successful in trained hands. It is meant to be a permanent method of sterilization for women who do not wish to expand their family. But 1 in 2000 may fail and result in pregnancy. There is also a possibility of ectopic pregnancy (which may need another laparoscopy or laparotomy) though ectopics are rare in sterilized than the non-sterilized. Laparosopy is associated with risks of injure y to bowel, blood vessels which may necessitate laparotomy. The cumulative pregnancy rates with 12 years of use of Cu-t and 5 years of use with Mirena are comparable to failure rates of lap sterilization. Though lap sterilization can be reversed at a later stage or In-vitro-fertilsation may be an option to conceive later, it is possible that both these may not be funded by the NHS. She is explained about vasectomy which is also a permanent method and a choice if she is in a stable relationship. Vasectomy is safer, faster, associated with less side effects and failure rates-1:20000.

The best way to minimize the risk of pregnancy is to perform lap sterilization in the immediate post-menstrual phase (follicular phase) and avoid it in the luteal phase. For a woman with irregular cycles, lap may be performed after withdrawal bleed. If the patient has an IUCD, it may be removed only at the time of sterilization to ensure continued contraception. Laparoscopy may be performed immediately in the cycle after oral contraceptive pill cycle. She is advised abstinence during the cycle of sterilization. Even if she is abstaining, it is prudent to do a pregnancy test before if she insists on a luteal period or near date sterilization. Check curettage at the time of sterilization is not recommended.

Posted by BHAWANA  P.

I would explore in her history regarding her future fertility wishes and parity as sterilisation is permanent method of contraception and she may wish to reconsider her decision. I will ask about her menstrual history- LMP, duration,regularity, flow of cycle as Mirena coil may be more suitable option if she has heavy menstrual bleeding or endometrial ablation can be done at the same time of sterilisation.I will ask about previous abdominal surgeries, caesarean section and type of incision- midline, transverse to decide method of sterilisation.Contraceptive history will help to address her concers regarding current method and discuss most appropiate choice according to her circumstances and ascertain that she is not pregnant before sterilisation.History of other systemic disease can influence mode of anaethesia and need to elicited .

On examination- BMI is important as obesity can make surgery difficult and experienced operator may be needed.General examination to rule out cardio-respiratory compromise will be done.Pelvic masses should be ruled out by abdominal and bimanual examination.

b) I would advise her that laparoscopic sterilisation is permanent method of contraception. Life time failure risk is 1:200. If she gets pregnant after the procedure, she is at increased risk of ectopic pregnancy and need to seek early medical attention.I will discuss about associated serious risks of laparoscopy- bladder/bowel/blood vessel injury ( 2/1000) and minor risks like shoulder tip pain, wound infection which are more common. There is  risk of conversion to laparotomy ( 1.4-3.0%). Any co-morbidities and obesity will increase the risk of operation and will be discussed individually.This is usually done under general anaesthetic and hence, inherent risks of GA will be discussed by anaesthesist.Reversal of sterilisation is not funded in NHS except under exceptional circumstances. Success rates of reversal varies from 0-60%. I will discuss about long acting reversible contraceptives- Mirena coil, Nexplanon,Progesterone only injectables with their risks and benefits. I will also discuss regarding vasectomy as life time failure rate of vasectomy is 1:2000. It is simple procedure performed under local anaesthetic.

c) She should be advised to use contraception/ abstinence at least after her LMP to avoid pregnancy as luteal phase pregnancy may not be detected before the procedure. Pregnancy test must be done before the procedure and if she is pregnant, sterilisation should be deferred.

Also, she should be advised to use barrier contraception or continue using current mode of contaception or abstinence till next period.

NA Posted by naila A.

(A)   I’ll take a detailed menstrual history including her LMP and regularity of cycles to assess the risk of luteal phase pregnancy after sterilization and exclude the possibility of pre existing pregnancy at the time of sterilization.Flow of  menstrul  blood should be asked as sterilization may be associated with pelvic congestion and menorrhagia and menstrual complications should be inquired such as dysmenorrhea and deep dysparunea to assess the risk of PID or endometriosis. I’ll obtain details of obstetric history including number of children, as low parity and also sterilization shortly after delivery is associated with regret, mode of delivery is important to assess the risk associated with laparoscopy. History of methods of contraception is important to assess her compliance and complications associated with contraceptive methods; also use of oral contraceptives is associated with decrease in menstrual flow which is sometimes interpreted as menorrhagia after sterilization. I’ll take her social history to know the type of job, shift duties are associated with contraceptive failure, use of drugs and binge drinking is associated with unplanned pregnancy, unstable relationship with partner and lack of support at home can be a pressurizing reason for a woman to ask for sterilization. Past surgeries on abdomen can increase the risk associated with laparoscopy. I’ll assess her BMI to assess the risk of failure of entry and note any scar on abdomen, midline surgery is associated with more complications. I’ll do abdominal and pelvic examination to exclude any mass.

(B)   I’ll inform her that sterilization is a permanent method and reversal is associated with low success rate. Currently the recommended method of tubal occlusion is using clips. The alternative methods for her with good efficacy are use of IUCD or mirena, particularly if she suffers from menorrhagia,  mirena is likely to be more suitable. I’ll inform her with risks and benefits of other long term contraceptive methods like injectables ,which have good efficacy and strict compliance with this method like remembering pill taking is not required, but associated with irregular bleeding and progestogenic side effects which are abdominal bloating ,mood swings , breast tenderness and weight gain.
Implants are also very effective for long term use. Implanon is licensed for 3 years use. It is reversible and associated with quick return of fertility, side effect is irregular bleeding. Another alternative is to offer vasectomy if she is in stable relationship. I’ll inform her about the risk associated with laparoscopy, serious risks are bowel or vascular injury which is 4 in 1000, risk of death is 1 in 12000.In case of failure to gain entry or need to repair visceral injury laprotomy is required.  The frequently associated risks are shoulder tip pain, bruising and wound infection. Life time risk of failure of this method is 1 in 200. Failure is associated more with the risk of ectopic pregnancy. I’ll inform her about the use of contraception to avoid luteal phase pregnancy and if she is using IUCD it should be removed after the next period. I’ll document my discussion and provide her with leaflets.

(C)   To minimize the risk of pregnancy I’ll counsel her about the risk of luteal phase pregnancy. If she is using IUCD it should be removed after next period. The surgeon should be appropriately trained. Hulka clips have more failure rate as compared to filshie clips. Correct technique should be used which is to apply filshie clips at right angle to tube 2 to 3 cm to cornu. At the end of the procedure the surgeon should ensure that whole length of tube is occluded. Diathermy should not be used, it is associated with more risk of ectopic pregnancy. Pregnancy test should be performed to exclude pre existing pregnancy. It will  not exclude luteal phase pregnancy.                            

Posted by K9 S.

Hello Paul

My answer wasn't corrected and I posted quite early. Would you check please whether it has been dropped by mistake.

Thank you

Regards

EMQ 354 Posted by Kshama U.

1)- I'll ask about her obstetric history, how many kids does she have, what was the mode of delivery, as that'll help in assessing the chances of intraabdominal adhesions if previous cesarean deliveries, also the time since last child birth to determine the interval between sterilisation and last child birth, whether the uterus has involuted completely.Then in her menstrual history i'd ask about the last menstrual period as i'd like to know at what day of cycle the sterilisation is being done, any previous contraception used, and if still using contraception, to determine the risk of pregnancy.Her past medical and surgical history to know about any abdominal or pelvic surgeries done, to assess the risk of intraabdominal adhesions. history of co-morbidities like diabetes, cardiovascular disease that'd increase anaethesia risk and risk due to pneumoperitoneum.In examination i'll calculate her BMI , if obese(BMI>30), difficulty during trocar entry may be there.General examination ,blood pressure,chest and cardiovascural assessment for anesthesia fitness.Perabdominal checkup for any scar marks of previous surgeries.pervaginal checkup to assess uterine size, any findings sugestive of pregnancy( soft cervix),any adnexal pathology,mobility of uterus, that'll affect my procedure.

2)-i'll tell the patient that laparoscopic sterilisation is done under general anaesthesia, we need to create a pneumoperitoneum. the method used is by tying a knot in the fallopian tube. that it is a permanent method of sterilisation, and the failure rate is less than 1in 100.the entry in the abdomen is by a needle, followed by a trocar.since this is a blind procedure, there may be a small risk of injury to intraabdominal organs, mainly peritoneum, intestine, or blood vessel. in case that happens, there may be a need to open the abdomen by laparotomy.

3)-to minimise the risk of pregnancy following sterilisation, i'd tell the women that if we have done the procedure midcycle, and she's sure there ws no chance of pregnancy, still she should use extra protection for 7 days following sterilisation . if she was on oral contraceptive pills then she should continue her packet till that cycle is over.if she was using copper-t device, that'd be removed only if the procedure was done immediate postmenstrual, or we can remove it in next post menstrual period.

Posted by BHAWANA  P.

Dear Paul,

Can you please check my answer? I think I was the last one to write.Thanks

answer Posted by Bindu R.

Please give us  the sample answer.

Hello Paul Posted by K9 S.

Hello.

I thikn you dropped my answer by mistake. I posted my SA early and before many other questions which have been corrected. Name is O.S and I don't have title for it thats why it has gone unnoticed. Would you have a look on it pls.

Many thanks

 

Posted by K9 S.

Thank you for correcting it

Regards

Posted by priyanka P.

good ans should contain what all points?

Posted by Hamdy H.

a)history of her parity as indication to complete her family and history of contraceptions as if she has been on contraception pills would experience heavier period after sterilization because of her normal periods come back. history of contraception as mirena is comparable to sterilization  can be reconvienced with mirena ask about partner or husband wish and acceptance of vasectomy. from clinical examination will generally fit . if obese will discuss laparscopic failure and risk and chance of laparatomy andits own inherent risks.abdominally scars from last operation makes laparscopy difficult and need different entry points.  vaginally size of uterus and exclude ovarian masses.

b)laparscopic sterilization is irrevesable operation if need reverse it will be costy and on your own expenses, failure is about 1in 200 vasectomy carries less failure 1 in 2000 and easy  and copareable if partner acceot. mirena is good alternative 99% success. 1 in 500 bowel injury and possible laparatomy if difficult access or bleeding.period may increase but not because sterilization but because been on pill for example before which reduced her period.

c) failure can be less if expert laparscopic surgeon ith coninued practice doing the operation. also exclude pregnancy bu a test regulary in DSU, Use two clips instead of one oneach side. senior anasthesit in obese patient will reduce risk of anasthetic failure.

wait untill next period on the same contraception been on see dr if missed period