2) Abnormal Cervical Smears

Cervical screening  in the UK has been a success in screening to prevent cervical cancer, about 4.4 million women are screened in the UK each year. Screening starts at the age of 25 and goes on till 65 years provided the last smears have been normal. 

No one knows what causes cervical cancer but there are associations with the human papilloma virus and cigarette smoking.

Recent advances in the screening and management process include screening for HPV types that have been linked with increased risk of developing cervical cancer and the use of Vaccines for prevention.

If abnormalities are found on screening they are usually graded as borderline, mild, moderate or severe. 

Depending on circumstance it may be decided that colposcopy is required. This is an investigation where the neck of the womb ( the cervix) is examined under magnification  (using an instrument akin to binoculars) to identify whether the abnormal cells found on the smear truly exist. If abnormality is found a biopsy may be taken and this will dictate whether further treatment is necessary. Sometimes treatment may be advised just on the basis of colposcopy.

Where treatment is required it is usually done by large loop excision of the transformation zone (LLETZ), with a local anaesthetic to numb the cervix.

The procedure takes about 10-15 minutes.  Women are advised not to undertake vigorous exercise, have intercourse or use tampons for 3-4 weeks after the procedure. They are advised to return or make contact if they have bleeding that is heavier than a heavy period, as bleeding is a potential complication of the procedure. Long term complications are uncommon; they include cervical stenosis( where the cervix becomes too tight) or cervical incompetence (where the cervix is unable to stay closed during pregnancy) this may result in miscarriage. This complication is rare occurring in less than 0.5% of women.

Over 90% of women will need no further intervention after the first treatment for others however follow-up may be required.

 

 

 

3) Complications of Early Pregnancy (Miscarriage):

Miscarriage presents with pain and or bleeding in early pregnancy, after missing a menstrual period. Unfortunately miscarriage is not uncommon. 1 in 8 pregnancies will miscarry. Once a woman has a positive pregnancy test within the first 3 months there is a 20% chance that she might miscarry. Between 6 and 9 weeks the risk falls to about 4% and after 9 weeks to 3% in the first trimester. The risk of miscarriage increases after a third miscarriage and with age.

From the early 1990s the management of miscarriage has changed in the United Kingdom with all units that care for women with complications of early pregnancy having dedicated areas and dedicated staff, who are experienced and versed in the management of complications of early pregnancy (Early pregnancy assessment units). These allow women continuity of care, provide counseling and support, and allow all tests and therapies to be carried out in dedicated areas, and avoid unnecessary and repeated internal examinations.

Once a woman experiences pain and bleeding in early pregnancy she will be referred to one of these units in her local area.

Miscarriages are usually defined as:

• Threatened: where there has been pain and or bleeding but the pregnancy is still ongoing.
• Inevitable miscarriage: where there has been pain and bleeding but the neck of the womb (cervix) is open to such an extent that nothing can be done to stop the miscarriage from progressing to pregnancy loss
• Incomplete miscarriage: where part of the pregnancy has already been lost and part remains in the womb
• Missed miscarriage: where the baby has already died within the womb but remains inside the womb

On arrival at the EPAU the objective would be to try and determine what type of miscarriage is taking place. A pregnancy test is usually organised and depending on how many weeks pregnant the woman is an ultrasound scan is then arranged. If the fetal heart is seen beating on the ultrasound scan she is reassured and in most cases sent home. If any of the above types of miscarriages is identified management choices are:

• Expectant: where the pregnancy is given the chance to come out by itself without medical intervention
• Medical: where medication is given to encourage the failed pregnancy to come out of the womb without the need for surgery
• Surgical management

Traditionally surgical management was the only therapy offered but depending on a woman’s symptoms and her preference she may be offered expectant or medical management. There are certain criteria that need to be met for safety and efficacy of the first 2 methods of management.

Whatever management is offered women are offered counseling for the emotional implications of miscarriage and how if necessary to manage future pregnancy.

 

 

 

4) Endometriosis

Endometriosis is a chronic condition where endometrium (this is the lining of the inside of the womb) is found outside the womb. It can be responsible for pelvic pain, pain during intercourse and in some women infertility.

It is common in the reproductive years but can also present in adolescence.

Unfortunately though it occurs in up to 10% of the general population with figures increasing in women with pelvic pain and infertility, Diagnosis is commonly delayed and women have often had numerous consultations before the eventual diagnosis is made

Though it is possible to diagnose some forms endometriosis with non- invasive techniques like ultrasound, the gold standard for diagnosis is a laparoscopy. This allows for the diagnosis to be made with certainty and the stage (severity) of the disease to be determined. It also allows the woman to make up her mind on how to manage her future fertility based on the information from the laparoscopy as fertility is known to decline after the age of 35 years and particularly so in women with endometriosis

The management of endometriosis requires a holistic and multidisciplinary approach as endometriosis not only affects the woman but may also affect indirectly other family members.

Management should be undertaken by experts who are not only familiar with the symptoms of the disease but also its natural history as endometriosis however treated has a recurrence risk and most women depending on the stage of endometriosis may require more than one surgery.

Initial management of endometriosis may be by the use of medicines or pain management therapy depending on the desire for immediate fertility. If fertility is not immediately desired then the pain symptoms can be managed with pain killers or in some cases the oral contraceptive pill.

Management multidisciplinary teams usually include a gynaecologist, a colorectal surgeon, urologists and pain management specialists as well as dedicated endometriosis nurses and support from counselors, physiotherapists and in some cases alternative medicine specialists. Women will only need to see certain specialists depending on their circumstance.

Women are also encouraged to join support groups to share experiences as in some cases a problem shared is a problem halved.

 

 

 

5) Ectopic Pregnancy:

Ectopic pregnancy is a pregnancy that is situated outside the womb. The most common site is the fallopian tube. It is a potentially life-threatening condition and occurs in about 1:100 pregnancies.

Common symptoms are abdominal pain and bleeding after missing a menstrual period, with a positive pregnancy test.

Risk factors for ectopic pregnancy include: previous ectopic pregnancy, previous tubal surgery, previous pelvic infection, current IUCD use. Though most women who present with ectopic pregnancy will have none of these symptoms.

Ectopic pregnancies are usually diagnosed on the basis of symptoms and a blood test which measures the amount of Beta-HCG which is a pregnancy related hormone, and an ultrasound scan.

For the majority of women it is possible to make a diagnosis after initial investigation but in some women the results of investigations may be inconclusive and follow up scans and blood tests may be necessary.

Once the diagnosis is established women may be given a choice of how they would prefer their ectopic pregnancy to be managed. The choice is sometimes limited however by symptoms and the results of investigations.

Choices include: 

1. Conservative, Expectant  management, where women are kept under surveillance until the pregnancy resolves by itself.

• This management depends on the initial pregnancy hormone level when this is less than 1000IU, this method of management is 70% successful.

2. Medical management: this is where a drug called Methotrexate is given to “kill” the rapidly dividing ectopic pregnancy cells. This modality of treatment depends on Beta-HCG levels and scan findings. The pregnancy may also take some time to resolve.

• For optimal chances of success the HCG level usually chosen is less than 3000IU, and there should be no fetal heart seen on ultrasound scan.
• Success is in the region of 88%.
• 15% of women may require a further injection.
• 7-10% of women may require surgical intervention.

3. Surgical management: the majority of women who have ectopic pregnancies are managed by surgery. Traditionally surgery used to be by conventional open surgery but now it is possible to manage nearly if not all ectopic pregnancies by means of laparoscopic surgery.

Despite evidence that laparoscopic surgery is superior to conventional surgery unfortunately not all women with this condition even if stable are managed by laparoscopic surgery with figures ranging from between 39% and 89% in india

Dr dasmahapatr has wide knowledge and research interest in this area. Under his direction  all (100%) women who are haemodynamically stable have laparoscopic surgery for the management of ectopic pregnancy when this is required. Even in haemodynamically unstable women 85% are managed by means of laparoscopic surgery by a highly skilled team of surgeons, nurses and theatre. 

Even for the rarer ectopic pregnancies Dasmahapatra has demonstrated that laparoscopic surgery is feasible.