GYNAECOLOGY
This section involves mainly the cohorts of pregnant women and the newborn, adult women of reproductive age (WRA), postmenopausal women, and sometimes infants and children in relation to sexual assault.
Abortion (Miscarriage)
The old working clinical definition of abortion denotes termination of pregnancy before 28th week of gestation. With advancement in modern neonatology the technical definition termination of pregnancy to a foetus weighing less than 500g. There are several types and clinical stages of abortion
Types
Therapeutic Abortion
Where the health of the mother and/or foetus is at risk, therapeutic abortion may be performed if recommended by two senior and experienced doctors as per the penal code section 240 and the Medical Practitioners and Dentists Board Code of Ethics and Professional Conduct “The punishment for unlawful termination of pregnancy is provided for in the Penal; Code sections 158, 159, and 160.”
Unsafe Abortion
WHO defines unsafe abortion as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both. Illegally induced unsafe abortion by mainly unqualified people is associated with incompleteness, sepsis, genital and visceral injuries, and death. This is usually an obstetric emergency
Threatened Abortion
Clinical Features
Mild abdominal pain and mild PV bleeding
Cervix closed
Investigations
Heamogram and blood group
Blood slide for malaria parasites in endemic malarious areas
Urinalysis and microscopy
Ultrasound examination to exclude “Brighted Ovum” or hydatidiform mole, and is reassuring if normal intrauterine pregnancy is seen
VDRL
Management
Order bed rest at home or in a facility.
For pain, offer hyoscine butyl bromide 20 mg TDS and/or paracetamol 1g TDS for 5 days.
Sedate with phenobarbitone 30 mg TDS for 5 days OR diazepam 5mg TDS for 5 days, to help allay anxiety and enforce bed rest.
Evacuate uterus if more bleeding and signs of progression to incomplete abortion occur.
Patient Education
If on bed rest at home, return to the health facility if features of progression to incomplete abortion intensify, e.g., more bleeding.
Abstain from sexual intercourse for at least 2 weeks to prevent progression to incomplete abortion and risk of infection.
Complete Abortion
Clinical features
Little or no bleeding or pain
Uterus contracted
Cervix closed
Investigations
Heamogram and blood group
Blood slide for malaria parasites in endemic malarious areas
Urinalysis and microscopy
Ultrasound examination to exclude “Brighted Ovum” or hydatidiform mole, and is reassuring if normal intrauterine pregnancy is seen
VDRL
Management
Resuscitate first with IV fluids (normal saline and dextrose) if the patient is in shock, consider blood transfusion if necessary. Free running till state of rehydration achieved.
Administer antibiotics: amoxicillin-clavulanate 625g BD OR doxycycline 500 mg QDS for 7 days and metronidazole 400 mg TDS for 7 days.
Give ferrous sulphate 200mg TDS and folic acid 5mg OD in standard dosage for 3 months. Ferrous sulphate should be given after completing the course of doxycycline.
Patient Education
If further pregnancy is desired, investigate further as under habitual abortion.
If further pregnancy is not desired, discuss and offer appropriate contraception.
Incomplete Abortion
Clinical features
Little or no bleeding or pain
Uterus contracted
Cervix closed
Management
Resuscitate with fluids (normal saline and dextrose); if the patient is in shock, transfer to higher level for appropriate management.
Give oxytocin 10 IU IM or ergometrine 0.5 mg IM STAT.
Remove POC from cervical os digitally or with ovum forceps.
Evacuate the uterus, preferable with manual vacuum aspiration (MVA) as soon as possible under para-cervical nerve block (10ml of 2% lignocaine HCL: 2.5ml injected at 2, 4, 8, and 10 o’clock positions of the cervix). NB: The uterus can be evacuated with either MVA or medication.
Misoprostol 300ug orally in a single dose will achieve completion in over 90% of the cases
For pain, IM diclofenac 75mg STAT
Give antibiotics: Doxycycline 500mg QDS+metronidazole 400mg TDS for 7 days.
Patient Education
If further pregnancy is desired, investigate further as under habitual abortion.
If further pregnancy is not desired, discuss and offer appropriate contraception.
Septic Abortion
Clinical Features
Little or no bleeding or pain
Uterus contracted
Cervix closed
Signs of infection
Investigations
Heamogram and blood group
Blood slide for malaria parasites in endemic malarious areas
Urinalysis and microscopy
Ultrasound examination to exclude “Brighted Ovum” or hydatidiform mole, and is reassuring if normal intrauterine pregnancy is seen
VDRL
Blood culture for patients in endotoxic shock
Management
Admit:
All cases having evidence of septic abortion
All patients in endotoxic shock
Where laparotomy is indicated
Where pelvic abscess develops
Resuscitate as in incomplete abortion.
If presentation is later or the sepsis is severe: Give IV crystalline penicillin 3 mega units 6 hourly and IV gentamycin 80 mg 8 hourly + metronidazole 500 mg 8 hourly for 3-5 days, also IM diclofenac 75mg 12 hourly.
If presentation is early and sepsis is mild: Give PO doxycycline 100mg 12 hourly OR PO amoxillin/clavulanate 375mg 8 hourly.
Plus PO metronidazole 500mg 8 hourly for 7 days plus PO ibuprofen 400mg 8 hourly for 5 days.
In severe cases, evacuate the uterus with MVA soon after initial antibiotic doses. In mild cases give misoprostol 600ug orally to achieve expulsion of the POCs.
Once stable, then may discharge on the above oral antibiotics and a pain killer.
Patient Education
If further pregnancy is desired, investigate further as under habitual abortion.
If further pregnancy is not desired, discuss and offer appropriate contraception.
Missed Abortion
Clinical features
History of amerrhoea
Symptoms of pregnancy regress.
Uterine size smaller than dates
Mid PV bleeding
Investigations
Heamogram and blood group
Blood slide for malaria parasites in endemic malarious areas
Urinalysis and microscopy
Ultrasound examination to exclude “Brighted Ovum” or hydatidiform mole, and is reassuring if normal intrauterine pregnancy is seen
VDRL.
Ultrasound, where available, will confirm foetal death.
Bleeding and clotting time in case disseminated intravascular coagulopathy (DIC) has developed.
Management
Admit the patient for definitive treatment.
If more than 12 weeks, induce with the prostaglandins tabs misoprostol 400ug per vagina. Observe for spontaneous onset of abortion process, then examine for complete abortion; if incomplete do MVA.
Then if less than 12 weeks, evacuate the uterus with MVA or misoprostol 800ug orally. Start on antibiotics PO doxycycline 100mg 12 hourly, PO metronidazole 400mg 8 hourly for 5 days, and PO ibuprofen 400mg 8 hourly for 3 days on discharge.
If complicated with DIC, fresh blood transfusion or fresh frozen plasma is lifesaving.
Patient Education.
If further pregnancy is desired, investigate further as under habitual abortion.
If further pregnancy is not desired, discuss and offer appropriate contraception.
Habitual Abortion
All cases of habitual abortion should be reviewed by a gynecologist.
Clinical Features
Three or more consecutive spontaneous abortions.
Investigations
As in threatened abortion, and
Blood sugar
Urine C&S
Blood grouping
Brucella titres
Widal test
Blood urea
Pelvic U/S
VDRLRPR
HIV Screening
Management
Management depends on the cause of the habitual abortion.
Correct anaemia and ensure positive general health.
If VDRL serology is positive, confirm syphilis infection with TPHA test, treat patient plus spouse with benzathine penicillin 2.4 mega units IM weekly for 3 doses. More often a single injection will suffice. In penicillin sensitivity, use erythromycin 500mg QDS for 15 days.
Control blood pressure to normal pre-pregnant levels.
Ensure diabetes is controlled.
For cases of recurrent urinary tract infections, order repeated urine cultures and appropriate chemotherapy.
For brucellosis positive cases, give doxycycline 500 mg QDS for 3 weeks + streptomycin 1g IM daily for 3 weeks. If pregnant, substitute cotrimoxazole for doxycycline.
Offer cervical cerclage in the next pregnancy in cases of cervical incompetence.
For cases with poor luteal function, give a progestin early in pregnancy, e.g., hydroxyprogesterone 500mg weekly until gestational age is 14 weeks. Then continue with oral gestanon 5mg TDS up to the 6th month.
TERMINATION OF PREGNANCY
Therapeutic abortion is termination of pregnancy for medical indications
Method of Therapeutic Abortion
May be surgical or medical
Surgical:
After 12 weeks: MVA or EVA
In 13th -18th week, dilatation and evacuation (D&E) after cervical priming with misoprostol 400ug for 3 hours.
D&E should only be performed by skilled and experienced doctors
Medical
In 13-22 weeks:
Give mifepristone 200mg orally, followed after 36-48 hours by misoprostol 400ug orally every 3 hours for 5 doses.
Or misoprostol 400ug orally every 3 hours for 5 doses
POST ABORTION CARE (PAC)
Unsafe abortion is common in Kenya and is often associated with serious access and psychosocial complications/problems. All women should have access to comprehensive quality services for the management of post-abortion complications. PAC services include resuscitation, evacuation of uterus by MVA, post-abortion counselling, education, and linkages to other reproductive health and support services. Fertility may return soon (11days) after an abortion. It also includes community participation. Family planning services help reduce repeat unsafe abortions. Midlevel providers (nurses and clinical officers) can be trained to provide PAC.
MOLAR ABORTION (HYDATIDIFORM MOLE)
Hydatidiform mole should be managed in levels 4, 5, and 6 because of its potential to progress to choriocarcinoma.
Clinical Features
A hydatidiform mole usually presents as a threatened or incomplete abortion. In the threatened stage, before the cervix opens, the diagnosis of hydatidiform mole is suspected if bleeding does not settle within a week of bed rest. The uterine size is larger than gestational age and foetal parts are not palpable.
Foetal movements are not felt at gestation 18-20 weeks and beyond. Features of hyperemesis gravidarum, nausea, vomiting, and ptyalism are still present and sever after 3 months. When the cervix opens, passage of typical grape-like vesicles confirms the diagnosis. Bleeding may vary when a mole aborts spontaneously.
Investigations
Positive pregnancy test in dilutions after 12 weeks gestation
Confirmation is by ultrasound.
Management
Treat shock with IV fluids or blood as necessary.
Put up oxytocin drip(20 IU in 500ml litre of normal saline or 5% dextrose at 20 drops per minute) for 4 hours or until drip is over and give IV antibiotics crystalline penicillin 3 mega units 6 hourly, gentamycin 80mg 8 hourly, and PO ibuprofen 400mg TDS.
Evacuate the mole with suction curettage; after evacuation continue oxytocin drip once the patient has stabilized. Discharge home on oral antibiotics (doxycycline 100mg 12 hourly and PO metronizole 400mg 8 hourly for 5 days) and ibuprofen 400mg 8 hourly for 5 days, and advice patient to return for admission for sharp curettage after 2 weeks.
Repeat sharp curettage to make sure all remains of the mole have been evacuated and send tissues for histology.
Provide reliable contraception for 1 year: combined pill, e.g., levonorgetrel 150ug thinylestradol, 30ug (microgynon or nordette) once daily for 3 weeks with breaks of 1 week in between is the best choice. Follow up monthly for pelvic examination and repeat pregnancy tests.
CHORIOCARCINOMA
Choriocarcinoma is confirmed while following the protocol of management of hydatidiform mole. The condition needs to be reviewed by a gynecologist.
Treatment depends on risk classification. Criteria for high risk (poor prognosis) is indicated by the following:
Duration of antecedent pregnancy event>4 months.
Beta HCG levels>40,000 IU/ML.
Metastases to the brain, liver, or GIT.
Failed chemotherapy (recurrence).
Following term pregnancy.
ECTOPIC PREGNANCY
Ectopic pregnancy is a pregnancy outside the uterine cavity, most of which are in the fallopian tube. It is usually due to partial tube blockage and therefore the patient is often sub-fertile. There are two types: acute ectopic pregnancy and chronic (slow leak) ectopic pregnancy. Differential diagnoses for this condition include pelvic inflammatory disease (PID), appendicitis, abortion, and ruptured ovarian cysts.
Clinical Features
For acute rapture ectopic pregnancy:
Amenorrhea 6-9 weeks.
Abdominal pain of sudden onset.
Shock and anaemia.
Abdominal distension and tenderness.
Shoulder tip pain due to haemoperitoneal diaphragmatic irritation.
Cervical excitation tenderness present.
For chronic (slow-leak) ectopic pregnancy:
Abdominal pain.
Irregular PV bleeding, usually dark blood (amenorrhea may be present).
Anaemia, fainting attacks.
Low grade fever.
Low abdominal and pelvic tenderness and possible a mass.
Cervical excitation present.
Investigations
Paracentesis of non-clotting blood is diagnostic in acute and some chronic cases
Culdocentesis in experiences hands is positive with dark blood, especially in chronic cases.
Group and cross-match blood. Hematocrit and/or haemoglobin estimation.
Management
Admit to comprehensive emergency obstetric care facility all patients suspected to have ectopic pregnancy.
Start IV line with saline and plasma expanders after obtaining specimen for grouping and cross-matching to treat shock.
Perform emergency laparotomy.
Perform routine salpingectomy of damaged tube. Make a note of the condition of the other tube and ovary in the record and discharge summary.
Where an experienced gynecologist is available, initiate conservative management of the affected tube.
Transfuse if necessary.
Discharge on haematinics.
Review in an outpatient gynecology clinic to offer contraceptives or further evaluate sub-fertility status.