Month: September 2015

Hysterosalpingogram

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What is Hysterosalpingogram ?

Hysterosalpingogram (HSG) is an X-ray test done to know about the patency of the fallopian tubes, which help in the transport of the egg and the fertilized embryo. It is usually done on 7th or 8th day of the menstrual cycle.

Hysterosalpingogram

Pic courtesy:   http://www.aiwhc.com/patient-education-hysterosalpingogram.html


Procedure and Instructions to be Followed for the Investigation

  1. In this test, a small amount of liquid (dye) is pushed into the uterus through a small instrument (speculum) placed in the vagina and an abdominal X-ray is taken. There can be period-like crampy pain during the procedure.
  1. To prevent pain, we advise Tab. Meftal spas to be taken with food, 1 hour before HSG and to continue it 8th hourly depending on the pain for the next two to three days.
  1. This test delineates the uterine cavity and the tubes. If the tubes are open, the dye flows out of the tubes and can be seen on the X-ray film.
  1. As this test involves pushing some liquid into the uterus, there can be a small risk of infection. In order to avoid this, we advise antibiotic Tab. Doxycycline 100 mg two times a day after food, starting from the day of HSG which has to be continued for a total of five days.
  1. Once HSG test is done, a gynaecology consultation (by appointment) with the report is advised.

Medical Ectopic Pregnancy

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Ectopic pregnancy (EP) is a pregnancy situated outside the uterine cavity (normal location). Early diagnosis of EP is possible with the advent of high resolution ultrasound and judicious use of serum Beta hCG levels (blood test), which in turn allow medical management in most cases. The choice of treatment should be guided by eligibility criteria and patient’s choice after discussing risks and benefits. Methotrexate (MTX) is the drug used for medical management of EP, sometimes in combination with mifepristone.

EctopicPregnancy

Pic courtesy:  http://www.innercircle.org/


Prerequisites for Medical Management

  • Asymptomatic women with unruptured EP who are clinically stable, have normal baseline blood investigations (blood counts, liver and kidney function tests) and are willing for regular follow-up for 4-6 weeks, can be offered medical management.
  • High serum Beta hCG levels (> 3500 mIU / ml), ectopic mass size > 3.5 cm and / or presence of cardiac activity in EP are relative contra indications to medical management.
  • It should not be offered to those with significant bleeding into the abdomen or those with a coexisting viable intrauterine pregnancy.

Methotrexate Administration

Two protocols are currently used for medical treatment of EP : “Single Dose” MTX therapy at a dose of 50mg/m2 of body surface area and “Multidose” regimen consisting of 1mg / kg of MTX alternating with 0.1mg / kg of leucovorin for upto 4 doses of each agent. Both regimens are found to be effective.

  • MTX can be given on Out Patient basis and intramuscular administration is the preferred route.
  • Multidose regimen is preferred in women with high serum Beta hCG levels or those with presence of cardiac activity on ultrasound. In the single dose regimen, further doses of MTX may be repeated (upto a maximum of 3) if there is an inadequate response (<15% drop in serum Beta hCG).
  • In the single dose regimen, further doses of MTX may be repeated (upto a maximum of 3) if there is an inadequate response (<15% drop in serum Beta hCG).

Laparoscopy is indicated if :

  • Severe abdominal pain or signs suggestive of tubal rupture develop.
  • There is no satisfactory drop in serum Beta hCG levels even after 3 doses in the single dose regimen or 4 doses in multidose regimen.

Anti D:

Regardless of the method of treatment Anti D should be given to all Rh negative women who have an EP.

Patient Should Be Advised To

  • Avoid sexual intercourse until Beta hCG is <10 mIU / ml.
  • Avoid pregnancy for three months after MTX injection, due to the theoretical risk of birth defects with MTX.
  • Avoid sun exposure to limit risk of MTX dermatitis.
  • Avoid foods and vitamins containing folic acid.

Post Treatment Management

Beta hCG  — Serial serum Beta hCG levels need to be checked on days 4 and 7 after MTX.

  • If there is >15% decrease between days 4 and 7, weekly follow up is advised until Beta hCG is <10 mIU / mL.
  • If <15% decrease is noted by day 7, 2nd dose of MTX is advised.
  • In multidose regimen, serum Beta hCG levels are checked every 48 hours till significant decrease is noted and weekly thereafter.

Ultrasound — It is generally not repeated except to evaluate severe pain or suspected rupture or for patients with cardiac activity in the EP.

After completion of treatment, an ultrasound is advised to check for resolution of the EP which may take upto 3 months at times.

Efficacy

  • Overall success of medical management is 88 – 90%.
  • Around 14% of patients require a 2nd dose and less than 1% of women require more than 2 doses of MTX.

Side Effects

Drug related

Adverse reactions to MTX are usually mild and self-limited. Approximately 30% of patients in the single dose protocol will experience side effects, the most common are mouth ulcers and conjunctivitis.

Separation pain

Up to 75% of patients may complain of pain between days 2-7 after receiving the medication. This pain is usually mild and can be managed with paracetamol. Women with severe pain require further evaluation to rule out rupture of EP and the need for surgery.

Subsequent Reproductive Performance

  • There is no evidence of adverse effects of MTX treatment on future pregnancies.
  • Studies have shown a subsequent intra uterine pregnancy rate of 60-90%.
  • The incidence of recurrent EP is approximately 7-15%.
  • Women should be instructed to undergo an early ultrasound evaluation in subsequent pregnancies to confirm normal intrauterine location.

Colposcopy

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What is Colposcopy ?

Colposcopy is a detailed examination of the cervix (neck of the womb). A colposcope is like a large magnifying glass which magnifies the image to approximately 15 times. It allows the doctor to look more clearly at cell changes in the cervix.

Colposcopy is simple, quick and generally painless. The actual examination takes only about 15 minutes. It is not done during menses. It can be done safely during pregnancy and will not affect delivery of the baby. However, treatment is usually postponed until after delivery.

Colposcopy

Pic courtesy:   http://dronuma.com.au/cervical-smears-colposcopy/

Why do I need a colposcopy ?

Colposcopy is usually indicated when the routine cervical screening test i.e. Pap smear test, has picked up abnormal cells from the cervix.

An abnormal result is not unusual – it happens in about one in twenty tests. An abnormal result usually means that small changes have been found in the cells on the cervix. It is important to remember that it is very rare indeed for these abnormalities to be cancer.

Colposcopy identifies the source of the cell change and helps to decide on further treatment. It is not a treatment by itself.

What exactly happens during a colposcopy ?

A speculum is passed into the vagina and the doctor applies different solutions onto the cervix to help identify and highlight any areas with abnormal cells. The abnormal areas will appear white after the application of vinegar (acetic acid 3 – 5 %). An iodine based stain may also be applied to the cervix to look for other abnormal areas. If any abnormal area is identified, a small sample of tissue (few mm in size) may be taken from the surface of the cervix for a biopsy. This is usually not painful.

It is necessary to wait for the biopsy results before deciding on further treatment. For some women the changes in the cervix return to normal by themselves. Other women may need some simple treatment.

What happens after colposcopy ?

After a colposcopic examination, normal activity can be resumed. If a biopsy has been taken, a light bloodstained discharge may occur for a few days following the procedure. This is normal and should clear by itself. It is best, however, to refrain from intercourse for up to five days to allow the biopsy site to heal.

Follow up

A review appointment with biopsy report will be scheduled in a week to 10 days’ time. Depending on the results of the biopsy, further treatment may be advised if required, or, one may be asked to return for a repeat pap smear in 6 months or routine screening.

Treatment options

If the biopsy warrants treatment, further procedures may be needed. Types of treatment vary, but all aim to destroy (cryotherapy) or to remove (loop excision) the abnormal cells. These treatments can be performed on an out-patient basis under local anaesthesia or under general anaesthesia.

Cryotherapy involves destruction of abnormal tissue by freezing it with nitrous oxide. It is a relatively painless procedure which takes around 15 to 20 minutes. After the cryotherapy, the frozen cells will slough off and new cells will grow underneath.

In loop excision, a small heated fine wire loop is used to remove the abnormal area from the cervix under local or general anaesthesia, and a sample is sent for analysis. The procedure may take around 20 to 30 minutes.

What happens after the treatment ?

Following cryotherapy, there may be watery vaginal discharge for 3 to 4 weeks.

Following loop excision, bloodstained vaginal discharge may be noticed for about two weeks, although it can last for 4 to 6 weeks.

The discharge should not be heavier than normal menses and should get progressively lighter. Abstinence from sexual intercourse is advised for six weeks. Follow-up is scheduled six weeks after cryotherapy or two weeks after loop excision.

Cervical Cancer

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Cervical Cancer CAN be avoided

The thought of cervical cancer is a particularly alarming one for all women, since no one knows exactly how it is caused. Many factors appear to be involved and not all of these will be present for every woman.

CervicalCancer

Pic courtesy:   http://www.healthcare-online.org/Cervical-Cancer-Symptoms.html

Why have a Cervical Smear Test?

Cervix is the lowermost part of the uterus. If detected early, the majority of cervical cancer cases can be avoided and the disease can be halted. Unfortunately, during the early stages there are no signs to tell a woman that she may be at risk. One of the simple ways to detect it, is by having a cervical smear test (also called a PAP SMEAR). Once it is discovered, treatment to counteract can be initiated. The early warning signals can be detected, which if left untreated could lead to cancer.

What is a Cervical Smear Test?

A smear test is a very simple way of checking the health of the cervix. By looking at the smear, experts can confirm if the cervix is normal and healthy, or abnormal. Presence of abnormal cells suggests cancer may develop in the future.

When to have the Smear Test?

  • Women between the ages of 20 – 60 years should do the test every 3 years.
  • Women who have excess / recurrent attacks of vaginal discharge or bleeding after sexual intercourse should do the test, regardless of their age.
  • It should be done within 10 days of the onset of periods.
  • There should be no bleeding at the time of the test.

How is a Smear Test done?

The smear test is a simple out patient procedure where the gynaecologist scrapes some of the cells from the cervix (the neck of the uterus), and smears it on a glass slide and sends it to the lab for examination.

What happens after the Test?

It takes 3-4 days to get the results from the lab. If the smear test is normal, (as it is in a majority of cases), then it should be repeated after 3 years.

If the test discloses some “abnormalities”, this usually means that some changes have occurred in the cells, which, if left untreated, could develop into cancer after many years. Remember, most women who have had an abnormal smear test are successfully treated.

Once treatment is started, it will be necessary to repeat the test after some months. If the subsequent smear tests are normal, then the tests should be done every 3 years.

If, however, the subsequent smear tests are not normal and continue to show some abnormalities, then it will be necessary to investigate further.

One of the easiest and most accurate ways of studying the cervix and confirming the disease is by undergoing a Colposcopy.

Cervical Cancer

Colposcopy?

Colposcopy is an in-depth examination of the cervix, through a special microscope called a colposcope. A colposcope acts like a magnifying glass with a light and allows the doctor to have a closer look at the cervix.

What happens during Colposcopy?

A Colposcopy examination is an out patient procedure, just like the smear test. A solution is applied to the cervix, which will cause any problem areas to turn white. The cervix is then viewed through the colposcope, which is placed just outside the vagina. If there are any abnormal areas on the cervix, a tiny sample of tissue is taken (biopsy) and sent to the lab for further testing.

After Colposcopy

There is no need for an overnight stay in the hospital after a Colposcopy. As mentioned earlier, it is an out patient procedure. If some tissue is taken from your cervix, you may experience some mild cramping or light bleeding for a few days, which can be relieved by any anti-inflammatory medication. It is advisable to abstain from sexual intercourse for a few days after a biopsy.

he results of the biopsy will determine the course of action to be taken. Feel free to talk to your gynaecologist about the type of treatment, the duration, and the options available.

Cervical Cancer