Abortion (miscarriage)

Abortion is the loss of a pregnancy before 24 weeks' gestation. 20-40% of pregnancies miscarry, mostly in the first trimester. Most present with bleeding PV. Diagnosis may not be straightforward (consider ectopics): have a low threshold for doing an ultrasound scan. Pregnancy tests remain +ve for several days after fetal death.

Management of early pregnancy bleeding

Consider the following:

• Is she shocked? There may be blood loss, or products of conception in the cervical canal (remove them with sponge forceps).
• Has pain and bleeding been worse than a period? Have products of conception been seen? (Clots may be mistaken for products.)
• Is the os open? The external os of a multigravida usually admits a fingertip.
• Is uterine size appropriate for dates?
• Is she bleeding from a cervical lesion and not from the uterus?
• What is her blood group? If RhD-ve does she need anti-D?

If symptoms are mild and the cervical os is closed it is a threatened abortion. Rest is advised but probably does not help. 75% will settle. Threatened abortion (especially second trimester) is associated with risk of subsequent preterm rupture of membranes and preterm delivery so book mother at a hospital with good neonatal facilities.

If symptoms are severe and the os is open it is an inevitable abortion or, if most of the products have already been passed, an incomplete abortion. If bleeding is profuse, consider ergometrine 0.5mg IM. If there is unacceptable pain or bleeding, or much retained tissue on ultrasound, arrange evacuation of retained products of conception (ERPC). Expectant management is used when the volume of retained products is small eg <15mm across on transvaginal scan; when 15-50mm, medical management eg with mifepristone may be offered (benefit may not be conclusive).17

Missed abortion

The fetus dies but is retained. There has usually been bleeding and the uterus is small for dates. Confirm with ultrasound. Mifepristone and misoprostol may be used to induce uterine evacuation if the uterus is small but 50% will require surgical evacuation if uterine products are >5cm2 in the trans- verse plane; >6cm2 in the sagittal plane.1 Surgical evacuation is required for larger uteruses.

Mid-trimester abortion

This is usually due to mechanical causes, eg cervical incompetence (rapid, painless delivery of a live fetus), uterine abnormalities; or chronic maternal disease (eg DM, SLE). An incompetent cervix can be strengthened by a cervical encirclage suture at ~16 weeks of pregnancy. It is removed prior to labour.

After a miscarriage

Miscarriage may be a bereavement. Give the parents space to grieve, and to ask why it happened and if it will happen again. Fetal products should be incinerated but if the mother requests alternative disposal (eg to bury herself) her wishes should be respected.1

Most early pregnancy losses are due to aneuploidy and abnormal fetal development; 10% to maternal illness, eg pyrexia. 2nd trimester loss may be due to infection, eg CMV. Bacterial vaginosis has been implicated. Most subsequent pregnancies are normal although at increased risk.

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Pelvic infection

Pelvic infection affects the Fallopian tubes (salpingitis) and may involve ovaries and parametra. 90% are sexually acquired, mostly chlamydia: 60% of these are asymptomatic (‚=1:1) but infertility or ectopic pregnancy may be the result, which is why screening has been proposedeg by a urine ligase chain reaction DNA: see BOX. Other causes, eg the gonococcus are rarer (14%if found, retest after treatment). Organisms cultured from infected tubes are commonly different from those cultured from ectocervix, and are usually multiple. 10% follow childbirth or instrumentation (insertion of IUCD, ToP) and may be streptococcal. Infection can spread from the intestinal tract during appendicitis (Gram ve and anaerobic organisms) or be blood-borne (tuberculosis).

Salpingitis

Patients with acute salpingitis may be most unwell, with pain, fever, spasm of lower abdominal muscles (she may be most comfortable lying on her back with legs flexed) and cervicitis with profuse, purulent, or bloody vaginal discharge. Heavy menstrual loss suggests endometritis. Nausea and vomiting suggest peritonitis. Look for suprapubic tenderness or peritonism, cervical excitation, and tenderness in the fornices. It is usually bilateral, but may be worse on one side. Subacute infection can be easily missed, and laparoscopy may be needed to make either diagnosis.

Management

♣Prompt treatment and contact-tracing minimizes complications. Take endocervical and urethral swabs if practicable. Remember to check for chlamydia. Admit for blood cultures and IV antibiotics if very unwell (eg ceftriaxone 2g/24h slow IV with doxycycline 100mg/12h PO) initially, then doxycycline 100mg/12h PO and metronidazole 400mg/12h PO until 14 days treated. Seek advice from microbiologist if gonorrhoea isolated. If less unwell give ofloxacin 400mg/12h PO and metronidazole 400mg/12h PO for 14 days. If infection is severe remove intrauterine contraceptive device (not needed if mild).1 Trace contacts (from within last 6 months and ensure they seek treatmentseek help of the genito-urinary clinic). Advise avoidance of intercourse until patient and partner treatments complete.

Complications

If response to antibiotics is slow, consider laparoscopy. She may have an abscess (draining via the posterior fornix prevents perforation, peritonitis, and septicaemiabut laparotomy may be needed). Inadequate or delayed treatment leads to chronic infection and to long-term tubal blockage (8% are infertile after 1 episode, 19.5% after 2, 40% after 3). Advise that barrier contraception protects against infection. Ectopic pregnancy rate is increased 10-fold in those who do conceive.

Chronic salpingitis

Unresolved, unrecognized, or inadequately treated infection may become chronic. Inflammation leads to fibrosis, so adhesions develop between pelvic organs. The tubes may be distended with pus (pyosalpinx) or fluid (hydrosalpinx).

Pelvic pain, menorrhagia, secondary dysmenorrhoea, discharge, and deep dyspareunia are some of the symptoms. She may be depressed. Look for tubal masses, tenderness, and fixed retroverted uterus. Laparoscopy differentiates infection from endometriosis.

Treatment is unsatisfactory. Consider long-term broad-spectrum antibiotics (eg tetracycline 250mg/6h PO 1h before food for 3 months), short-wave diathermy and analgesia for pain, and counselling. The only cures are the menopause or surgical removal of infected tissue.

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The cervix

This is the part of the uterus below the internal os. The endocervical canal is lined with mucous columnar epithelium, the vaginal cervix with squamous epithelium. The transition zone between them the squamo columnar junction is the area which is predisposed to malignant change.

Cervical ectropion

This is often called erosion, an alarming term for a normal phenomenon. There is a red ring around the os because the endocervical epithelium has extended its territory over the paler epithelium of the ectocervix. Ectropions extend temporarily under hormonal influence during puberty, with the combined Pill, and during pregnancy. As columnar epithelium is soft and glandular, ectropion is prone to bleeding, to excess mucus production, and to infection.

Treatment

Cryocautery will treat these if they are a nuisance; otherwise no treatment is required.

Nabothian cysts

These mucus retention cysts found on the cervix are harmless.

Treatment

Cryocautery if they are discharging.

Cervical polyps

These pedunculated benign tumours of endocervical epithelium may cause increased mucus discharge or postcoital bleeding.

Treatment

In young women they may be simply avulsed, but in older women treatment usually includes D&C to exclude intrauterine pathology.

Cervicitis

This may be follicular or mucopurulent, presenting with discharge.

Causes

Chlamydia (up to 50%), gonococci, or herpes (look for vesicles). Chronic cervicitis is usually a mixed infection and may respond to antibacterial cream. Cervicitis may mask neoplasia on a smear.

Cervical screening

Cervical cancer has a pre-invasive phase: cervical intraepithelial neoplasia (CIN not to be pronounced sin'). Papanicolaou smears collect cervical cells for microscopy for dyskaryosis (abnormalities which reflect CIN). A smear therefore identifies women who need cervical biopsy. The degree of dyskaryosis approximates to the severity of CIN (Table, p 273). ~50% of CIN I lesions return to normal but most CIN III lesions progress to invasive carcinoma. This may take ~10yrs, but may happen much faster in young women.

In the UK from 2005 it is recommended that 1st smear be taken at aged 25, then 3 yearly until 49 years, 5 yearly from 50 to 64 years and only to screen after 65 years if one of the last 3 included an abnormal result. Those most at risk are the hardest to trace and persuade to have screening, eg older women, smokers, and those in inner cities. 83% of the eligible UK population is now screened, and mortality here is starting to fall; this depends critically on being able to retain skilled lab staff.

Taking a smear

Explain the nature and purpose of the test, and how results will be conveyed. Warn that results are not always unequivocal.

The cervix is visualized with a speculum (p 242). Are there any suspicious areas? If so, carry on with the smear and indicate this on the referral form, but do not wait for its results before arranging further care.

Cells are scraped from the squamo-columnar transformation zone with a special spatula or brush, then transferred to a slide and fixed at once. Liquid based cytology (LBC)1 involves rinsing the sampler or detaching its head into a vial of liquid creating a cell suspension from which slides are prepared which are quicker and easier to screen than conventional smears. The suspensions can also be tested for herpes virus and chlamydia. Inadequate smear rates are reduced with LBC. Good technique is needed (make sure that all 4 quadrants of the cervix are sampled); it is best to learn by instruction from an expert at the bedside.

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The uterus

Endometritis
Uterine infection is uncommon unless the barrier to ascending infection (acid vaginal pH and cervical mucus) is broken, eg after abortion and childbirth, IUCD insertion, or surgery. Infection may involve Fallopian tubes and ovaries.

Presentation
Lower abdominal pain and fever; uterine tenderness on bimanual palpation. Low-grade infection is often due to chlamydia.
Tests
Do cervical swabs and blood cultures.
Treatment
Give antibiotics (eg doxycyline 100mg/12h PO with metronidazole 500mg/8h PO, eg for 7 days).

Endometrial proliferation
Oestrogen stimulates endometrial proliferation in the first half of the menstrual cycle; it is then influenced by progesterone and is shed at menstruation. A particularly exuberant proliferation is associated with heavy menstrual bleeding and polyps.
Continuous high oestrogen levels (eg anovulatory cycles) make the endometrium hyperplastic (cystic glandular hyperplasia' ”a histological diagnosis after D&C). It eventually breaks down, causing irregular bleeding (dysfunctional uterine bleeding).
Treatment
Cyclical progestogens (p 253).
In older women proliferation may contain foci of atypical cells which may lead to endometrial carcinoma (p 278).

Pyometra
This is a uterus distended by pus eg associated with salpingitis or secondary to outflow blockage.
Treatment
Drain the uterus, treat the cause.

Haematometra
This is a uterus filled with blood due to outflow obstruction. It is rare. The blockage may be an imperforate hymen in the young (p 246); carcinoma; or iatrogenic cervical stenosis, eg after cone biopsy.

Endometrial tuberculosis
Genital tract tuberculosis is rare in Britain, except among high-risk groups (eg immigrants). It is blood-borne and usually affects first the Fallopian tubes, then the endometrium.
It may present with acute salpingitis if disease is very active, or with infertility, pelvic pain, and menstrual disorders (40%) eg amenorrhoea, oligomenorrhoea. There may be pyosalpinx. Exclude lung disease by CXR.
Treatment is medical with antituberculous therapy (OHCM p 564 “7). Repeat endometrial histology after one year. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is treatment of choice if there are adnexal masses and the woman is >40yrs.1

Uterine ultrasound2
Transvaginal ultrasound gives better resolution than transabdominal (as the probe is closer to the target and a higher frequency transducer can be used). Homogeneity, echoes of low intensity and presence of a linear central shadow are associated with absence of endometrial abnormality. Endometrial carcinoma is suggested by endometrial thickness >20mm (>5mm if postmenopausal not on hormones), heterogeneous appearance, and hypoechoic areas. Polyps have cystic appearance (also with hyperechoic endometrium).
If postmenopausal and not on HRT, double-layer endometrial thickness should be <5mm (if perimenopausal <5mm on day 5 of cycle). Sequential hormone replacement  †‘endometrial thickness (average 5 “8.5mm); if on continuous combined replacement HRT thicknesses are ~4.5 “7mm; tibolone treated endometrium <5mm; but tamoxifen thickens it to ~13mm. It thins down by 6 months after stopping tamoxifen, then stays thin.22
Ultrasound is useful for detecting fibroids; and assessing cystic change in rapidly growing fibroids to assess risk of malignant change.
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Sexual health

Sexual health is the enjoyment of sexual activity of one's choice, without causing or suffering physical or mental harm. Of course there is more to sex than enjoyment.  Perhaps the sexual life is the great test. If we can survive it with charity to those we love, and affection to those we have betrayed, we needn't worry so much about the good and the bad in us. But jealousy, distrust, cruelty, revenge, recrimination… then we fail. The wrong is in that failure even if we are the victims and not the executioners. Virtue is no excuse

Once one understands that human sexuality is infinitely complex, it is easier to appreciate statistics such sexual dysfunction is a big health problem, affecting 43% of women and 31% of men.

Enemies of sexual health include:

• Disharmony in personal relationships, or simply too many relationships.
• Pain, or any medical, or gynaecological condition.
• Anxiety (whether or not related to fear of failure); depression; fatigue.
• Drugs (eg tamoxifen; the Pill; cyproterone; antidepressants; narcotics).
• A multiplicity of irreconcilable roles (if your patient is trying to achieve ascendency in her work, as well as being chief shopper, cook, housewife, mother, and friend, then the role of lover may be eclipsed all the more if she also finds herself in the role of being chief person to blame if things go wrong if the fridge is empty, if the money runs out, if the children do not get to school on time, or if her partner loses his job).
• Myths about sexual performance (eg that all physical contact must lead to sex, that sex equals intercourse, and that sexual relations should come naturally and easily).

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