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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

Course PAID
notes	336
EMQ	1502
SBA	2115

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ESSAY 139 - HYSTEROSCOPY D&C

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		Posted by Sarwat F. Thu Jan 20, 2005 08:09 am
I will ensure that the investigation is performed after taking the patient’s informed consent by explaining the whole procedure the risks and the chances of having complications, anaesthetic if any proposed to be administered, in terms which in my judgement are suited to the patient’s understanding to the patient as well as to one of the parents or guardian of the patient. I will also enquire if there is anything which she does not understand or if she wants more information I will make sure that it is provided to her. She will also be told that procedure may not be done by the doctor who has been treating her so far and that any procedure in addition to the investigation or treatment described on the consent form will only be carried out if it is necessary and in her best interest and can be justified on medical reasons. I will then ask her to sign the consent form. The procedure can be safely performed under local anaesthesia and should be offered to the patient. To minimize the morbidity associated with this procedure patient should be provided with information leaflets containing detailed description of the procedure, its advantages and disadvantages. These should also preferably be discussed in the clinic while making the decision. The procedure can be performed under local, regional or general anesthesia and depending on the patients medical condition procedure with minimal side effects that is local or regional block is offered. As far as the equipment is concerned flexible endoscope use is associated with high patient acceptability. Surgical risks include uterine perforation, injury to intraabdminal viscera, primary hemorrhage. To prevent these complications this procedure must be carried out by a trained person or by a trainee under supervision as there is a risk of physical morbidity. Trauma to the cervix can be reduced by administering the hysteroscope under direct vision. Complications specific to hysteroscopy include fluid overload, anaphylactic shock and gas embolism. Patient’s electrolytes must be checked before the procedure and careful estimation of fluid intake and output during surgery is critical. Correct pressure insufflators should be used. Early postoperative complications include infection and secondary hemorrhage. Prophylactic antibiotics should be given before the procedure including ampicillin. After the procedure specimen is sent for histopathology and it is made sure that the results will be contacted to the patient and accordingly decisions are taken.
		Posted by vijaya L. Thu Jan 20, 2005 04:45 pm
Informed consent involves providing evidence based information, allowing her to comprehend and ask questions to clarify the doubts and sign it only if it is fully acceptable to her. Day care procedure is associated with time constraint. Hence the discussion about the procedure should happen before hand and she should be given reading material which gives her ample time to go over the information. She should be explained about the procedure of hysteroscope introduction, visualization of uterine lining and taking material for pathological examination with help of pictures preferably. Hysteroscopy and D&C can be done under paracervical anaesthesia but some units use general anaesthesia and hence risks of remote mortality due to anaesthesia should be explained (this depends on the category of anaesthetic risk she belongs to). Alternatives like office endometrial sampling by Pipelle or Vibra aspirator (likely to sample only 40% of the endometrial surface), blind D&C without hysteroscopy (likely to miss polyps) should be explained. Risks as a result of hysteroscopy even though rare, the generally quoted figures are 6/ 1000 risk of perforation, 4/1000 risk of infection, 3/1000 risk of haemorrhage, and 2/1000 risk of possibility of unintended procedure. She should also be given the information about the 20% chance of finding either premalignant or malignant lesions, which require further procedures or treatment. When she reaches the day surgery unit she should be allowed time to voice her questions and concerns. The consent form should contain the name of the procedure, need for the procedure, alternatives, type of anaesthesia and complications. Accurate Preop assessment of the medical and anesthetic risk of the woman is essential to reduce the complications history of allergies to the medication should be taken. Swabs should be taken from the cervix and vagina or universal antibiotic prophylaxis with metronidazole is provided along with a broad spectrum cephalosporin. A trained person should be doing the procedure. Hysteroscopy with D&C requires basic hysteroscopy training. Accurate fluid balance should be noted continuously instead of intermittently. Perforation can occur during the dilatation or during the material collection and if there is active bleeding backup facilities for laparoscopy or laparotomy and expertise should be available.
		Posted by Nibedita R. Fri Jan 21, 2005 08:21 am
In order to obtain an informed consent, adequate information relating to the procedure, its intention, risks and benefits, anaesthetic requirement and its complications, available alternatives and the result of not doing this should be discussed enabling her to decide whether or not to have the procedure. I would tell her that diagnostic hysteroscopy is the procedure that involves introducing a telescope through the neck of the womb to view the inside of the womb. While doing this, a small sample of tissue would be taken for examination in the laboratory to determine the cause of the bleeding. Although, benign pathology in the endometrial lining causes post menopausal bleeding in most of the cases, in 8-10% a malignancy may be found. As this is a diagnostic procedure it would not be able to alter her symptoms, but will help to plan the treatment according to the pathology report. Although it may be possible to examine the lining of the womb by a non invasive procedure like ultrasound which would measure the thickness of the lining but would not reliably tell a definitive diagnosis, as malignancy may also arise from an atrophic endometrium. Dilatation and Curettage or endometrial biopsy may be alternative procedures to hysteroscopy. But D/C is capable of sampling only less than half of the endometrial surface whereas endometrial biopsy using a pipelle plastic cannula can sample only 4.2% of the womb lining. A hysteroscopy even though involving direct vision of the lining can miss about 3% of cases. Most women would experience only mild crampy pain in the lower abdomen, slight vaginal bleeding or shoulder tip pain following the procedure; serious risk involves uterine perforation, pelvic infection, failure to visualise uterine cavity. Prolonged heavy bleeding, offensive vaginal discharge, tender swollen abdomen, severe pain or pyrexia in the post operative period should be reported by the patient to the hospital or GP promptly. She should be instructed to avoid sexual intercourse for 1-3 weeks following the procedure. She should be informed that an extra procedure like laparoscopy in the event of perforation (0.76%) may be necessary during the procedure and very rarely blood transfusion in the case of heavy bleeding. The woman must be aware of the anaesthesia (General or Local) planned and be given an opportunity to discuss this in detail with the anaesthetist before the procedure. Other procedures which may be appropriate but not essential at the time should be discussed, such as removal of any polyp identified during hysteroscopy. All information provided should be documented and supported by information leaflets. To reduce morbidity from the procedure the surgeon should be appropriately trained and a trainee must perform the procedure under supervision and should involve senior colleagues in a timely fashion when difficulties arise. Postoperative infection can be reduced by giving prophylactic antibiotics. Evacuation of bladder immediately before the procedure would reduce risk of injury to bladder. Some studies suggest use of misoprostol to dilate the cervix preoperatively. Vasopressin to inject paracervically to constrict the vessels around the cervix would minimise blood loss. Introduction of the scope should be under direct vision. Use of local anaesthesia for diagnostic hysteroscopy would reduce complications related to GA. If GA is used for intolerable or anxious patient, meticulous preoperative assessment should be done. Laparoscopy should be performed when perforation is suspected. Laparotomy if indicated should be done involving a bowel or vascular surgeon. Fluid overload is one of the possible and dangerous complications leading to cardiac arrythmias, pulmonary and cerebral edema, which can be reduced by keeping a record of fluid used and returning using a hysteromat. Use of CO2 for uterine distension may lead to gas embolism and should be avoided. Hemorrhage may complicate the procedure in 1-2 % cases. If uncontrollable, a Foley balloon should be introduced to create tamponade. Early recognition and management of postoperative complication in a timely manner would reduce morbidity.
		Posted by Iman B. Fri Jan 21, 2005 09:14 am
The aim of the procedure must be understood by the patient, that it is necessary to do the hysteroscopy and D&C to exclude any pathology in the endometrium, and stop the bleeding until the result of the pathology, The possibility of missing out on this procedure means that a possible malignancy if this were the cause may be missed. The procedure should be explained in detail to the patient, that a hysteroscope is inserted thru the vagina and under vision the cavity of the uterus is checked for any lesions, and a D& C performed at the conclusion of the procedure. The fact that the biopsy will be taken for pathology should also be explained and when the results will be due. She should be informed of the use of anesthesia and that she will get a chance to discuss her medical condition/s as well as the type of anesthesia to be used with the anaesthetist prior to the surgery. She should be told of the risks of the operation that perforation is rare, occurring in eight in every thousand women, and that if it does occur it may necessitate the use of a laparoscopy, to view the abdomen to check there is no injury of internal organs or bleeding. She should be informed of the rare possibility of bleeding becoming excessive, if perforation occurs, which may make blood transfusion necessary, and her wishes regarding blood transfusion should be documented. The fact that infection may occur and that this risk decreases if antibiotics are given before the operation, any allergies should be noted. The fact that this is not curative but rather investigative must be stressed, and that according to the results of both the hysteroscopy and the pathology, further operative procedures may become necessary. The patient will need to know that this is a one day procedure and she may be discharged as soon as the surgeon and the anaesthetist are sure she is well, she might have to stay overnight. Small side effects of the procedure will occur, as cramping in the lower abdomen or shoulder pain, and the patient must be assured that these are rarely severe, and usually resolved within the first few days. Discharge and bleeding must also be explained to the patient and that discharge is not dangerous and usually goes within two weeks, the bleeding if it persists, should be appropriately treated, and the fact that this procedure is not a cure for the initial compliant should be stressed. The procedure is usually videotaped, and the patient should be told, and her approval or refusal taken for the use of this for teaching or research purposes. All this should be documented, preferably with a witness to the discussion, who is recorded in the notes The morbidity arises from either the anesthesia, in case the patient has any medical complaint, in which case the anesthetist should see the patient and her medical notes prior to the procdure, to ensure that she is fit. Another problem arises from incorrect positioning of the patient on the operating table, injuries of the brachial plexus, foot drop and back aches can be avoided, if the patients shoulders are put on a nonslip mattress rather than a hard wooden positioner. The arms should not be hyperabducted on the wooden slab for too long, and the legs should be lifted simultaneously and not hyperabducted. Fluid overload is caused by inattention to the pressure and amount of fluid being used. One person in the theatre should be responsible for this and the pressure should not exceed 80mmhg, and the input and output carefully monitored. Perforation of the uterus is avoided by careful vaginal examination for the size of the uterus and entering the hysteroscope under vision. Bleeding will be caused by perforation or by excessive traction on the cervix, with consequent tears; the cervix should be handled gently, and a tough cervix should have been diagnosed prior to the procedure and prostaglandins used to soften it before starting.Pelvic inflammation is avoided by prophylactic antibiotics prior to the operation.
		Posted by Vaijayanti R. Fri Jan 21, 2005 10:29 pm
Informed consent not only keeps the patient abreast of her planned investigations/ treatment; but ensures good communication between the consultant and the patient.It is based on the facts that the treating doctor is responsible for obtaining the consent and every adult is presumed to be competent enough to give consent unless proved otherwise. I will organize an appointment for counselling, at her convinience.Any special requirements ( interpretor) will be met. She is also informed that she can bring a companion or request for the consultation to be taped for later reference. Detailed counselling will involve giving accurate and precise information regardingthe proposed procedure using verbal and written information, audio visual aides etc. The main risk of post menopausal bleeding is that of malignancy; though the incidence is low ( 8% of women with post menopausl bleed will have a malignancy) and most women have no detectable underlying cause.Other causes would include endometrial hyperplasia,polyps, submucous fibroids etc. The procedure planned will involve direct visualization of the uterine cavity ( hysteroscopy) and collection of endometrium for histopathological examination. The advantage of the hysteroscopy is that it will allow us to collect specimens from suspicious sites , and also identify other probable causes of bleeding ( polyps, submucous fibroids etc ; upto 95.5% accuracy). The main disadvantage of the procedure is that it is diagnostic, and further definitive treatment ( if necessary) will have to be planned at a later date. As it is an office procedure , the operating time is shorter,and no anesthesia is involved. However, local anesthesia is given to avoid any pain.Post operative analgesia will be offered on request. The names of the Consultants involved will be given to her. Specific consent is asked for if trainee doctors are to be present at the procdure. Informed consent is documented in the patients notes and appropriate forms are to be filled.Details of the information given and any specific requests made by the patient are recorded.It must be remembered that implied consent or apparent compliance does not mean informed consent She is also informed that she can change her mind whenever she wants to and has the right to seek a second opinion. In the eventuality of her not being competent to give consent, the opinion of a senior , experienced colleague will be sought. The procedure may still be carried out in keeping with the principle of ?best interests ? of the patient. Adequate time is given for her to think and decide on giving consent.The scope of the consent must be clearly defined and should not be crossed on any account. The risk of morbidity associated with office hysteroscopy is very low 0-1%;common causes include anesthetic,distension media related and, perforation, bleeding,infection. Adequate pre procedure counselling is important in reducing morbidity. Systemic disorders ( cardiovascular , endocrine) which may alter management must be ruled out/ treated before the procedure. She should be asked to come in on an empty stomach( to reduce the risk of aspiration) and be accompanied by a responsible adult to take her home.Test dose of local anesthetic given before the procedure will identify inherent hypersensitivity.Emptying the bladder before the procedure will reduce the risk of catheterization and subsequent infection. Cleaning the vagina and cervix with povidone solution / maintaining asepsis will reduce the incidence of infection. Paracervical block will provide adequate analgesia Avoid dilating the cervix as much as possible. If it needs to be done, care must be taken to avoid trauma and perforation. The hysteroscope is introduced carefully.Fluid used is preferably normal saline as this is a diagnostic procedure.Avoid sudden excessive distension of the uterus; maintain pressure below the MAP.Avoid the use of CO2( embolism) , water as distension media. The input/ output chart for fluid introduced into the uterus should be strictly maintained. Performance of the procedure by a surgeon well versed on the technique will reduce morbidity
		Posted by vijaya L. Sat Jan 22, 2005 11:17 am
Hello paul the figures i quoted were from the notes
		Posted by Rani M. Thu Jan 27, 2005 12:44 am
Please can anybody tell me about RCOG document, how to assess it as I don\'t have it. Dear Paul, can u please tell me about notes on hysteroscopy are in which heading. ( confused)
		Posted by narmin B. Thu Jan 27, 2005 06:43 am
Obtaining an informed consent form is essential before hysteroscopy and D&C under general anaesthetic. It ensures that the patient understands the aim, benefits and risks of the procedure and possibility of having additional procedures if necessary. In the majority of cases the woman has already been consented in a pre-operative clerking clinic. Nevertheless, on the day of surgery the consent form should be reviewed by the operating doctor for completeness. Patient should be asked whether she has understood the benefits and risks of the procedure and if there was any questions it should answered clearly. If she has not been consented before, an informed consent should be obtained. It should be explained that hysteroscopy involves passing a narrow telescope into the uterine cavity under general anaesthetic in order to identify presence of any abnormality and to take a biopsy form lining of the uterus and the procedure has no therapeutic effect. It should be told that in most of the cases hysteroscopy and D&C is a straightforward operation and she will be able to go home in a few hours after the procedure. There is possibility of failure to visualise the uterine cavity. Common and rare complications of the procedures also should be explained. Common complications are abdominal pain, vaginal bleeding and discharge. Rare complications are perforation of the uterus one in 200 cases, damage to bowel or bladder which can happen one in 500 cases. Additional procedures, laparoscopy and laparotomy may be required in case of damage to the uterus or other organs. This information should be documented on the standard consent form and patient must sign and date it. Surgical morbidity due to hysteroscopy and D&C are uterine perforation, intraoperative bleeding, damage to intrapertoneal organs and failure of the procedure. Having adequate experience in performing hysteroscopy and D&C reduces the rate of failed operation, uterine perforation and damage to other organs. If ultrasound scan of the uterus is available it should be reviewed, as it gives an idea about the size, shape and other abnormalities of the uterus. If the patient has had cone biopsy, transcervical resection of endometrium (TCRE), dilatation of the cervix and visualising the cavity may be difficult and excessive force should not be used as it may cause false passage and uterine damage. Also history of caesarean section and myomectomy in the past can increase the risk of uterine perforation, and extra care should be taken. Bimanual examination under anaesthetic before the operation for uterine size and position is necessary. Uterus should be sounded before the procedure to assess depth and the direction of the uterine cavity. Controlled insertion of the cervical dilators reduces damage to the cervix and uterus and intraoperative bleeding. If there was any complication, operation should be stopped and a senior colleague should be informed. In case of small uterine damage patient should be kept in the hospital overnight. Laparoscopy/ laparotomy is required if any serious damage was suspected.