GYNECOLOGIC PROCEDURES AND SURGERY pdf

841 GYNECOLOGIC PROCEDURES EXFOLIATIVE CERVICAL CYTOLOGIC STUDY (PAPANICOLAOU SMEAR) Exfoliative cytologic examination of specimens from the lower gen- ital tract (Pap smear) is a screening tool that has been so valuable in the detection of premalignant and malignant lesions that it has been almost universally adopted as the primary cancer screening method for cervical cancer, an integral part of the health care of women. This has resulted in a Ͼ50% reduction of invasive cancers of the cervix alone. Although cervical cytology may detect en- dometrial cancer (in 15%–50%), it does not carry the same relia- bility as a screening tool for endometrial neoplasia. SCREENING GUIDELINES ● Initial gynecologic screening at age 18, or when the indi- vidual becomes sexually active. ● Women whose initial smear is negative (without significant atypia) should have a second smear within 1 year to rule out a false-negative smear. ● High-risk women should be screened annually (i.e., those with a history of early sexual activity or those with multi- ple sexual partners). ● Low-risk women may be screened every 1–3 years at the dis- cretion of the physician. These are women with late expo- sure to coitus, those with only one sexual partner, and women after two successive negative annual smears. (Some authorities contend it is too difficult to ascertain low risk and simply recommend annual screening.) 31 GYNECOLOGIC PROCEDURES AND SURGERY CHAPTER Copyright 2001 The McGraw-Hill Companies. Click Here for Terms of Use. BENSON & PERNOLL’S 842 HANDBOOK OF OBSTETRICS AND GYNECOLOGY ● Postmenopausal women should receive annual screening. ● Women after hysterectomy should have an initial smear fol- lowing surgery; if this is negative, cytology should be re- peated every 3 years. TECHNIQUE Materials necessary for a Pap smear include a cervical spatula, shaped tongue depressor or cotton swab, glass slides and a means to identify the slide and patient, a speculum (warm, without lubri- cant), and a jar of fixative (97% ethanol) or spray fixative (e.g., Pro-Fixx or AquaNet) (Fig. 31-1). The objective is to sample secretions from the endocervical canal, the transformation zone, and the vaginal pool. The last site is less productive and, therefore, of lesser priority. Sampling is ac- complished by gently wiping away excess mucus and obtaining en- docervical canal samples using the moist cotton swab or cervical spatula. This is smeared onto a glass slide and fixed. A spatula with an endocervical extension, or similar device is used to lightly scrape the entire transformation zone. In those with a small external os, a brush device may be helpful in guaranteeing that endocervical cells are sampled. This sample is spread on a slide and fixed immedi- ately. Finally, the vaginal pool may be sampled by using the same spatula (again, fixing immediately). The reporting of cervical cyto- logic results is discussed on p. 524. COLPOSCOPY The colposcope is a binocular microscope of low magnification (10–40ϫ) used for direct visualization of the cervix. Although col- poscopy does not replace other methods of diagnosing cervical ab- normalities, it is an important additional tool. The patients who most benefit from colposcopy are those with abnormal Pap smears. Col- poscopy is also used to evaluate women who were exposed to DES in utero and in gynecologic cancer therapy follow-up. Occult neoplasms in the upper cervical canal, where 10% –15% of cervical cancers develop, cannot be detected by colposcopy. Therefore, endocervical curettage should be performed in women who are being evaluated for abnormal cervical cytology. Normally, columnar epithelium covers the ectocervix until ado- lescence, when it gradually changes to a squamous surface. The transformation zone can be inspected easily with the colposcope, and dysplastic surface changes can be identified. These include white epithelium (e.g., sheet of layered metaplastic cells), a mosaic pattern (e.g., sharply outlined cells and cell groups), punctation (e.g., CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 843 FIGURE 31-1. Preparation of a Papanicolaou cytosmear. BENSON & PERNOLL’S 844 HANDBOOK OF OBSTETRICS AND GYNECOLOGY vascular tufts between cell clusters), and leukoplakia (e.g., abnor- mal pale cell plaques). Colposcopy allows recognition of cellular dysplasia and vas- cular or tissue abnormalities not otherwise visible. Colposcopy al- lows selection of cancer-suspicious areas for biopsy. A green filter accentuates the vascular changes (which frequently accompany pathologic alteration). Dilute (3%) acetic acid solution is used to remove mucus and to facilitate visualization. Other chemical agents and stains may also be used to improve visualization. A camera at- tached to the colposcope facilitates follow-up. Colposcope-directed biopsy decreases the number of false-negative reports and may elim- inate the need for conization of the cervix, a cause of morbidity. To perform colposcopy, proceed as follows. ● Insert a speculum and visualize the cervix. ● Cleanse the cervix with 3% acetic acid. This removes ex- cess mucus, blanches the surface, and accentuates normal epithelium. ● Focus the colposcope on the cervix, beginning with low power (usually 13.5ϫ). Inspect the squamocolumnar junc- tion (transformation zone) carefully. A significantly abnor- mal area usually can be fully outlined. ● Take biopsy specimens with a Kevorkian or similar biopsy forceps, and record the sites most suggestive of cancer. ● Consider whether endocervical curettage should be per- formed. Effective use of the colposcope requires thorough training and extensive experience. EVALUATION OF PATIENT WITH ABNORMAL CERVICAL CYTOLOGY In summary, a normal smear requires follow-up as noted previously. Atypical squamous cells of undetermined significance identifies cells that need further studies to identify if they are reactive or neoplas- tic. In these cases, if there is clinical infection, treatment against the offending agent with repeat cytology 6–8 weeks after the infection is eliminated and the tissue has healed may be all that is necessary. The more ominous nature of atypical glandular cells of undeter- mined significance requires an evaluation for endocervical, en- dometrial, tubal, or ovarian pathology. Low-grade squamous intraepithelial lesions (LGSIL) include grade I cervical intraepithelial neoplasia (CIN), also termed mild dysplasia, and human papillomavirus lesions. Whereas high-grade squamous intraepithelial lesion (HGSIL) includes moderate and severe dysplasia (CIN II and III). Thus, when these reports are re- turned, prompt colposcopy is warranted. Any abnormal areas must be biopsied, and endocervical curettage must be performed. Possi- ble invasive cancer requires immediate colposcopy and biopsy (in- cluding conization if necessary). CULDOCENTESIS (See Ectopic pregnancy, p. 311) SOUNDING THE UTERUS The uterus may be sounded to determine the patency of the cervi- cal canal, the presence of cervical or uterine lesions that will bleed on contact, the size of the uterus, the position of the uterine fun- dus, and the direction of the uterine canal (before endometrial biopsy or other instrumentation). Intrauterine pregnancy must be ruled out before uterine sounding. Use a sterile, malleable, cali- brated (in centimeters) instrument (e.g., Sims or Simpson uterine sound). Visualize the external cervix with a speculum, and carefully ap- ply an antiseptic solution (e.g., povidone-iodine). Bend the sound to the estimated curvature of the cervicouterine axis. After warning the patient of possible slight pain, grasp the cervix (on either anterior or posterior lip) by a double-toothed Braun or Allis clamp and ex- ert gentle traction toward the introitus, using the nondominant hand. This immobilizes the cervix and straightens the endocervical canal. Use the index finger and thumb of the dominant hand to gently insert the sound in the cervicouterine axis while pressing the third and fourth fingers against the vulva to brace the hand. A slight, tran- sient resistance may be encountered at the level of the internal os. An obvious obstruction is encountered at the vault of the uterine cavity. Exert special care to avoid perforation of the uterus at the level of the cervicouterine junction (particularly in marked flexion) and at the top of the fundus. Note the length of the cervical canal, the direction of the axis, the depth of the uterine cavity, and any obstruction, distortion, or free bleeding. In the absence of cervical stenosis and extreme flexion of the corpus, gentle traction and sounding of the uterus cause only a few slightly menstrual-like cramps. Careful patient preparation and anal- gesics, if necessary, make the procedure tolerable. If sounding of the uterus is impossible with the usual instru- ments, it may be initiated using a fine, soft wire probe, followed by Hegar dilators (#5–10). The diagnosis of an abnormally wide CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 845 BENSON & PERNOLL’S 846 HANDBOOK OF OBSTETRICS AND GYNECOLOGY internal cervical os (notably incompetent) is confirmed if #8 Hegar dilator passes without resistance. BIOPSIES VULVAR (See p. 588) CERVICAL Multiple cervical biopsies may be performed in the office with lit- tle or no discomfort or danger, using Tischler, Schubert, Kevorkian, or similar punch biopsy forceps. Polypoid lesions may be removed by torsion or excision (Figs. 31-2 and 31-3). For microscopic analy- sis, do not crush the tissue. Anesthetics are not required because the cervix is relatively insensitive to this type of pain. After detailing the areas to be biopsied by colcoscopy, immo- bilize the cervix using a tenaculum. First biopsy the posterior lip (so bleeding from more anterior biopsies will not obscure the field). The most frequent biopsy sites are at or near the squamocolumnar junction. Place the tissue in fixative (e.g., 10% formalin) immedi- ately. Bleeding is variable and unpredictable. If necessary, control bleeding by pressure, Negatol, acetone, 5% silver nitrate solution, or fine catgut sutures. ENDOCERVICAL CURETTAGE This procedure is commonly used as an adjunct to colposcopy in an effort to guarantee sampling of the entire endocervix. Stabilize FIGURE 31-2. Multiple punch biopsy of cervix with Tischler. the cervix using a tenaculum or Allis clamp, and curette the endo- cervix throughout its circumference by taking downward strokes from the internal to the external os with a Kevorkian or other small curet. Fix these strips of tissue immediately and submit them for pathologic diagnosis. Anesthesia is rarely required, the procedure generally is very short (Ͻ2 min), and bleeding is minimal. The prin- cipal complication is uterine perforation (usually at the cervi- couterine junction). CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 847 FIGURE 31-3. Three methods of cervical polypectomy. BENSON & PERNOLL’S 848 HANDBOOK OF OBSTETRICS AND GYNECOLOGY ENDOMETRIAL BIOPSY For endometrial biopsy, no anesthesia or only mild analgesia or paracervical block is required. Contraindications to endometrial biopsy include pregnancy; marked cervical stenosis; acute cervici- tis; friable, bleeding cervical abnormalities; and profuse bleeding at the initiation of endometrial curettage. The most common endometrial biopsy instrument currently used is a tubular plastic device for aspiration of strips of endometrium. After antiseptic preparation, sound the uterus. Next, direct the curet to the fundus and gently stroke downward against the uterine wall to the cervix while exerting gentle suction. Perform on both ante- rior and posterior uterine walls. Place the tissue obtained in fixa- tive immediately. INDUCED ABORTION DEFINITION, INCIDENCE AND ASSOCIATIONS In the United States, elective abortion is persistently controversial. Our purpose is to provide timely information, not to debate issues or enter into controversy. Therefore, in this summary there is no at- tempt to influence patients or health care providers for or against abortion, and none should be inferred. The statistical data in the fol- lowing is summarized from the most authoritative source available at the time of writing, (i.e., Koonin LM, Strauss LT, Chrisman CE, Montalbano MA, Bartlett LA, Smith JC. Abortion Surveillance— United States, 1996, Morbidity and Mortality Weekly Report, July 30, 1999, 48:1–42). The U.S. Centers for Disease Control and Prevention (CDC) de- fines legal induced abortion as a procedure performed by a licensed physician or someone acting under the supervision of a licensed physician, that was intended to terminate a suspected or known in- trauterine pregnancy and to produce a nonviable fetus at any ges- tational age. Absolute numbers of abortions are not as sensitive an index of utilization by women in the reproductive years as are the abortion ratio (the number of abortions per 1000 live births per year in a given age group) and the abortion rate (the number of abor- tions per 1000 women in a given age group per year). Table 31-1 summarizes annual data for the United States. U.S. legal abortion utilization has stabilized following the de- cline experienced earlier this decade. Whereas those Ͻ15 years have the highest ratio (723), older women (40–44 years) also have a higher ratio (376) of legal abortion. Ratios are lowest in women age 30–34 years (165). For over a decade, those with highest fertility rates (age 20–34 years) have had a stable abortion ratio. Rates are highest for women age 20–24 years (38%) and lowest at the re- productive extremes Ͻ15 years (2%) and 40–44 years (2%). Associations with legal abortion utilization include age, race, and marital status. Women Ͻ25 years have Ͼ50% of legal abortions, and 32% are performed in the 20–24 year age group. White women com- prise ϳ57% of women having legal abortions; but the white ratio of 202 is less than the ratio in black women (555), and women of other races (360). The legal abortion rate for black women (31%) is 2.6 times the rate for white women (12%). Unmarried women have 78% of legal abortions, more than 8-fold that of married women. Most (54%) were obtaining a legal abortion for the first time, although 18% had at least two prior abortions. No previous live births had occurred in 43%, and ϳ87% of those having a legal abor- tion had Յ2 previous live births. More than one half of all abor- tions (55%) were performed at Յ8 weeks of gestation, and ϳ88% were performed before 13 weeks. Approximately 4% of abortions were obtained at 16–20 weeks, and 1.5% were obtained at Ն21 weeks. Younger women (i.e., women aged Յ24 years) were more likely to obtain abortions later in pregnancy than were older women. Currently, nearly all (98%) of abortion are performed by curet- tage. Less than 0.5% are by intrauterine saline or prostaglandin ad- ministration. Complete data are available for 1992 when 10 women died as a result of complications from legal induced abortion (a case-fatality rate 0.7 abortion-related deaths per 100,000 legal induced abortions). CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 849 TABLE 31-1 NUMBER, RATIO AND RATE OF UNITED STATES LEGAL ABORTIONS Year Number Ratio Rate 1970 193,491 52 5 1975 854,853 272 18 1980 1,297,606 359 25 1985 1,328,570 354 24 1990 1,429,577 345 24 1995 1,210,883 311 20 1996 1,221,585 314 20 BENSON & PERNOLL’S 850 HANDBOOK OF OBSTETRICS AND GYNECOLOGY INDICATIONS The most controversial abortions are totally elective (patient de- mand). Social indications for interruption of pregnancy are proba- bly the next most debated indications and cover a broad spectrum: preservation of mental health, excessive family size, poverty, in- cest, and rape. Perhaps the least controversial are those termed “medically in- dicated.” Examples of medical diseases said to require interruption of pregnancy to preserve maternal life or vital functions include neuropsychiatric disorders (authorities disagree regarding qualifi- cations), bilateral renal insufficiency, chronic resistant pyelonephri- tis, class III or IV cardiac disease (e.g., intractable atrial fibrillation, coronary occlusion), marked impairment of pulmonary ventilation (vital capacity of Ͻ1400 mL in the average-size person), progres- sive loss of vision or Kimmelstiel-Wilson syndrome in patients with diabetes mellitus, thromboembolic disorders, severe hemo- globinopathies, gammaglobulinopathies, clotting defects, severe ul- cerative colitis, invasive cervical cancer, and advanced breast car- cinoma. Obstetric complications that seriously affect the fetus when abortion should be considered include rubella before 12–14 weeks gestation, severe isoimmunization, fetuses with known morphologic defects (e.g., anencephaly, acardius), and fetuses with known con- genital disorders (e.g., Tay-Sachs disease, osteogenesis imperfecta, trisomy 13). LABORATORY STUDIES Ultrasound scanning both confirms the pregnancy and aids in de- termination of gestational age. If no fetal sac or fetal heartbeat is present, a qualitative hCG is performed, and if positive, a quanti- tative value obtained. An hCG of Ն1750, in the absence of a fetal sac should alert the physician to the possibility of an ectopic preg- nancy. COUNSELING The provider has the responsibility to explain the reputed advan- tages, disadvantages, and alternatives of elective abortion, just as with other procedures. Additionally, the patient should be assured of continued empathetic quality care whatever her decision. The patient must be informed about the nature of the procedure and its risks, including possible infertility or even continuation of pregnancy. All reasonable alternatives must be explored. The rights [...]... with CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY FIGURE 31-14 Uchida method of sterilization 867 868 BENSON & PERNOLL’S HANDBOOK OF OBSTETRICS AND GYNECOLOGY dissection into the peritoneal cavity This operation is often performed under analgesia and local anesthesia The uterus is elevated (by a uterine sound inserted before surgery or by use of a small intraabdominal retractor), and adequate visualization... or previous surgery (especially cesarean section) The procedure is facilitated if there is uterine prolapse The patient is placed in the dorsal lithotomy position, and the vagina and pudendum are prepared with an antiseptic solution Sterile drapes are applied, and a posterior weighted speculum is placed CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 873 in the vagina The cervix is grasped, and mobility... with the other prostaglandins, PGE2 suppositories must be repeated, result in a rapid abortion (8–12 h), and include all the side effects noted above, plus chills and fever Hysterotomy and Hysterectomy Abdominal or vaginal hysterotomy, major surgery, has the disadvantage of much higher morbidity and should be avoided if possible 854 BENSON & PERNOLL’S HANDBOOK OF OBSTETRICS AND GYNECOLOGY Hysterectomy,... bee cell) distend the vagina, elevate the cervix, and reduce cystocele and rectocele by direct pressure Inflatable pessaries function similarly If the perineum is inadequate, CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 857 these pessaries may require a perineal belt and pad for support The Napier pessary has a cup–stem arrangement supported by a belt and affords uterine support for a prolapsed cervix... investigations, removal of polypoid leiomyomas, and in operative management of a subseptate uterus Contraindications to hysteroscopy include pregnancy, acute cervicitis or salpingitis, the presence of STDs, and hemorrhage GYNECOLOGIC SURGERY DILATATION AND CURETTAGE (D & C) Dilatation of the cervix and curettage of the endometrium (D & C) is the most common gynecologic surgical procedure If D & C is being... the vagina and perineum with an antiseptic and place the drapes Insert a weighted speculum into the posterior vagina Visualize, then grasp the cervix with a tenaculum or Allis clamp Curette the endocervical canal with a Kevorkian or similar curette Sound the uterus Dilate the cervix using progressive CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 859 TABLE 31-2 INDICATIONS FOR DILATATION AND CURETTAGE... (generally up to 20 weeks—called dilatation and evacuation, D & E) require several osmotic dilators or graduated mechanical dilators, a larger suction cannula, and forceps to complete CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 853 evacuation Although this technique has fewer complications than the various methods for induction of uterine contractions and is more rapid than induction of contractions,... report less frequent orgasm and regret the procedure STERILIZATION IN THE MALE Male sterilization by vas ligation (an office procedure) is far less dangerous than female sterilization This alternative should be offered to the couple who desire limitation of childbearing, particularly when the woman is not an appropriate candidate for surgery CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 869 TABLE 31-3... x-ray, and ECG for those Ն45 years, and a stool guaiac determination Uncomplicated hysterectomy rarely requires transfusion Hence, type and screen for possible transfusion is often used in many institutions, as opposed to the more costly and timeconsuming type and crossmatch procedures The vagina should be prepared with povidone-iodine douches or a similar antiseptic the night before or the morning of surgery. .. prostaglandin (PGF2a, 40 mg), intravaginal prostaglandin vaginal suppositories (E2, 20 mg), and intramuscular 15-methyl PGF2␣ The coagulation system is altered temporarily by injection of hypertonic saline (decreased fibrinogen and platelets, increased fibrin degradation products) and the patient’s fluids and electrolytes must be monitored carefully The noninvasive techniques (using prostaglandins) . hysterotomy, major surgery, has the disadvan- tage of much higher morbidity and should be avoided if possible. CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 853 BENSON & PERNOLL’S 854 HANDBOOK OF. Figures 31-5 and 31-6. The Hodge pessary (Smith-Hodge, or Smith and other CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 855 FIGURE 31-5. Types of pessaries. BENSON & PERNOLL’S 856 HANDBOOK OF. cervi- couterine junction). CHAPTER 31 GYNECOLOGIC PROCEDURES AND SURGERY 847 FIGURE 31-3. Three methods of cervical polypectomy. BENSON & PERNOLL’S 848 HANDBOOK OF OBSTETRICS AND GYNECOLOGY ENDOMETRIAL