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GY6 Gynecology
Every woman of childbearing age presenting to ER with abdominal or pelvic pain should have β-hCG measured
Common Investigations and Procedures Toronto Notes 2019 Common Investigations and Procedures
Imaging
Ultrasound (U/S)
• transabdominalortransvaginalU/Sistheimagingmodalityofchoiceforpelvicstructures
• transvaginalU/Sprovidesbetterresolutionofuterusandadnexalstructures
■ detects early pregnancy if β-hCG ≥1,500 (β-hCG must be ≥6,500 for transabdominal U/S)
• maybeusedtoidentifypelvicpathology
■ identify ectopic pregnancy, intrauterine pregnancy
■ assess uterine, adnexal, cul-de-sac, and ovarian masses (e.g. solid or cystic) ■ determine endometrial thickness, locate/characterize fibroids
■ monitor follicles during assisted reproduction
■ assess endometrial lining in postmenopausal women
Endometrial Biopsy
• performedintheofficeusinganendometrialsuctioncurette(pipelle)guidedthroughthecervixto aspirate fragments of endometrium
■ pre-treatment with misoprostol (Cytotec®) is optional
• moreinvasiveprocedure(D&C)maybedoneintheofficeoroperatingroom±hysteroscopy.This
may be required if endometrial biopsy is not possible in the office setting or if there is suspicion for an
endometrial polyp
• indications
■ AUB/PMB ◆ age >40
◆ risk factors for endometrial cancer
◆ failure of medical treatment
◆ significant intermenstrual bleeding
◆ consider in women with infrequent menses suggesting anovulatory cycles
Hysterectomy
Indications
• uterinefibroids
• endometriosis, adenomyosis
• uterineprolapse
• pelvicpain
• AUB
• cancer(endometrium,ovaries,fallopiantubes,cervix)
Complications
• generalanesthetic
• bleeding
• infection
• injurytootherorgans(ureter,bladder,rectum)
• lossofovarianfunction(ifovariesremoved,iatrogenicmenopause)
Approaches
1. Open (abdominal approach): uterus removed via transverse (pfannenstiel) or midline laparotomy 2. Minimally invasive approaches
■ vaginalhysterectomy:entireprocedureperformedthroughthevagina.Noabdominalincisions ■ laparoscopic assisted vaginal hysterectomy: vascular pedicles are divided by a combination of
laparoscopic and vaginal approaches
■ totallaparoscopichysterectomy:allvascularpediclesincludingthecolpotomyapproached
laparoscopically and removed through the vagina.
■ robotic:atypeoflaparoscopicapproach.MaybeadvantageousinhighBMIpatients.Morecostly
Surgical Approach to Hysterectomy for Benign Gynaecological Disease
Cochrane Database Syst Rev 2015;(8):CD003677 Summary:
1. Vaginalhysterectomyisassociatedwithafaster return to activity when compared to laparoscopic or abdominal hysterectomy.
2. Ifvaginalhysterectomyisnotfeasible, laparoscopic hysterectomy is associated with faster recovery and less infections than abdominal hysterectomy.
3. Total laparoscopic hysterectomy was associated with more injuries to the urinary tract.
4. Overall,thenumberofadverseeventsislow and surgical approach should be determined after careful evaluation of specific risks and benefits.