Wits Gynaecology Protocol and Management Guidelines

Introduction and General Clinical Comments

• Target Audience: These guidelines are intended as a practical guide for registrars, medical officers, interns, and medical students at University of the Witwatersrand Academic Hospitals.
• Contributors: W W Edridge, F Guidozzi, E J Buchmann, K Frank, A Wise, E Bera, H Rhemtula, and others.
• Spelling: Both American (e.g., gynecologist, hematologist) and English (e.g., gynaecologist, haematologist) spellings are accepted and included.
• Patient Communication: Explain everything (blood tests, surgery, prescriptions) without jargon or abbreviations. Use indigenous South African languages if English is not known.
• Medical Record Keeping: Findings and management must be recorded with date and time in the patient’s file. Note that smartphone entries are often too brief.

Blood Test Protocols for Specific Conditions

• Miscarriage: Hb, Compat (Typed and Held) if necessary, U&E, Rh.
• Septic Miscarriage: FBC, U&E, ABG, PI/PTT, HIV, Compat.
• Ectopic Pregnancy: Hb, U&E, hCG (in uncertain cases), Rh, Compat.
• Gestational Trophoblastic Disease (GTD): FBC, U&E, hCG, thyroid functions, Compat if necessary.
• First Trimester Termination: Rh, Ward Hb if slightly pale.
• Second Trimester Termination: FBC, U&E, Rh, Compat.
• PID Grade 1 (Out-patient): None required; HIV if unknown.
• PID Grade 2: FBC, U&E, HIV, CRP/PCT (optional), Compat.
• PID Grade 3/4: FBC, U&E, HIV, Compat, ABG if necessary, CRP, PCT if unwell.
• Oncology Presentation: FBC, U&E, HIV, CD4, VL (LFT rarely).
• Epithelial Ovarian Cancer: Above plus CA-125, CEA, LFT.
• Germ Cell Ovarian Tumor: Above plus AFP, hCG, LDH, LFT.
• Granulosa Cell Tumour: Inhibin (if available), LFT, E2 if post-menopausal.

Blood Transfusion and Surgical Guidelines

• X-Match (Cross-Match) Timing: Typed and held samples (Compat) can be cross-matched in $30-40$ minutes, which is usually fast enough for theatre. Only request X-match if Hb is $< 10$ for most operations.
• Necessary X-Match Indications: Ovarian malignancy, large fibroids, immobile masses, molar pregnancy evacuation, and abdominal pregnancies.
• Massive Transfusion/DIC: Request Fresh Frozen Plasma (FFP) and consider platelets. X-match early.

Clinical History and Physical Examination

• The "Big Five" Questions:
  • Age
  • Parity and gravidity
  • Last menstrual period (LMP)
  • Current contraception method
  • Marital status and occupation (patient and partner)
• Pain Assessment: Duration, severity, localization, association with menstrual cycle, dyspareunia, urinary/bowel symptoms, and alleviating/aggravating factors.
• Bleeding Assessment: Amount, duration, clots, pain association, and discharge.
• Systematic Examination:
  • General: Vitals (heart rate, temperature, BP, respiratory rate), mucous membrane color, and HIV stigmata (wasting, oral thrush, lymphadenopathy).
  • Abdominal: Inspection for scars/hernias; palpation for organomegaly (liver, spleen, kidneys, uterus, ovaries) and tenderness (guarding/rebound); percussion for ascites.
• Pelvic Examination Rules:
  • Empty bladder before the exam.
  • Always perform a speculum exam before a bimanual exam.
  • Use a small amount of lubricant on speculum blades (avoid tips when taking smears).
  • Speculum Insertion: Part labia with the left hand, aim downwards with blades horizontal. If resistant, wait or turn vertically, then revert to horizontal.
  • Bimanual Exam: Use one or two fingers in the vagina; press the abdominal hand downwards and towards the vagina.
• Rectal Examination: Mandatory for any pelvic/vaginal mass, gynae cancer, or suspected endometriosis to assess parametrium and recto-vaginal septum.

Lower Abdominal Pain (LAP) Differential Diagnosis

• Pelvic Inflammatory Disease (PID): Cervical motion tenderness is essential. Often overdiagnosed.
• Irritable Bowel Syndrome (IBS): Causes $50\%$ of all LAP in women. Pain is chronic/intermittent; tenderness is in iliac fossae/suprapubically (higher than PID). Bimanual exam is normal.
• Dysmenorrhea:
  • Primary: Begins with menarche, starts $24$ hours before flow, lasts $24-48$ hours.
  • Secondary: Starts $24$ hours before flow, lasts through the period; caused by fibroids, endometriosis, adenomyosis, or chronic PID.
• Endometriosis/Adenomyosis: Chronic pain worsening with menses; deep dyspareunia; potential infertility. Adenomyosis is felt as a tender, boggy uterus.
• Ovarian Cyst Accidents: Torsion (sudden severe pain), rupture, or bleeding. Ultrasound distinguishes between functional follicles ($2.5\,cm$) and pathological cysts.
• Wait and Prove: Ectopic pregnancy and miscarriage must always be considered in any patient of reproductive age with LAP.
• Lumbosacral Root Pain: Referred pain; worse on movement or rising; no abdominal signs.
• Acute Appendicitis: Abdominal signs typically exceed pelvic findings; positive Rovsing’s and Psoas signs.

Pelvic Inflammatory Disease (PID) Management

• Gainesville Grading:
  • Grade I: Acute salpingitis without peritonitis.
  • Grade II: Acute salpingitis with peritonitis.
  • Grade III: Acute salpingitis with tubo-ovarian complex or tubal occlusion.
  • Grade IV: Ruptured tubo-ovarian complex/generalized peritonitis.
• Outpatient Management (Grade I/II, Temp $< 38^{\circ}C$, Pulse $< 100$):
  • Ceftriaxone $250\,mg$ IM stat (in $0.9\,ml$ lidocaine $1\%$).
  • Doxycycline $100\,mg$ PO BD for $14$ days.
  • Metronidazole $400\,mg$ PO BD for $14$ days.
  • Alternative: Azithromycin $1\,g$ stat (repeated after $1$ week).
• Inpatient Management (Grade II-IV):
  • Penicillin G $6\,million\,units$ IV $6$ hourly OR Ampicillin $500\,mg$ $6$ hourly.
  • Gentamicin $240\,mg$ IV daily OR Amikacin $1\,g$ IV daily.
  • Metronidazole $1\,g$ rectally BD OR $500\,mg$ IV $12$ hourly.
  • Second-line: Tazocin $4.5\,g$ IV $12$ hourly (may be used).
• Surgical Indications: Mass not responding to treatment, renal failure, dusky/necrotic cervix, or generalized peritonitis.

Early Pregnancy Problems: Ectopic Pregnancy

• Well Patients: Positive hCG, empty uterus on scan, and free fluid in Pouch of Douglas (POD).
• Observation/Conservative Criteria:
  • hCG $> 5000\,U/L$ on transabdominal scan or $> 1000\,U/L$ on transvaginal scan with empty uterus suggests ectopic.
• Medical Management (Methotrexate):
  • Requirements: Well patient, unruptured, no fetal heartbeat, diameter $\le 3.5\,cm$, hCG $< 10,000\,mIU/ml$.
  • Protocol: Methotrexate $50\,mg/m^2$ or $75\,mg$ IM/PO single dose. FBC, U&E, LFT must be checked first.
  • Failure: $20\%$ require surgery.
• Surgical Management:
  • Standard: Total salpingectomy.
  • Conservative: Salpingostomy/salpingotomy (preserving the tube).
  • Shocked Patients: Resuscitate with two IV lines ($14$ or $16$ gauge), X-match $4$ units packed cells, urgent laparotomy.

Miscarriage Management

• Threatened: Bleeding, closed cervix, viable fetus. Reassure (at least $90\%$ continue if fetal heart active).
• Inevitable: Open cervix, pain, bleeding, no products passed.
• Incomplete: Open cervix, products passed/visible.
  • Management: MVA if $< 14-16$ weeks and stable. If unstable: IV Ringer-Lactate + Oxytocin $20\,units$ in $1\,L$.
• Complete: Positive test, empty uterus on scan, history of heavy bleeding with passed products.
• Septic Miscarriage: Hypotension, offensive products, tachycardia, pyrexia.
  • Management: Triple IV antibiotics, emergency evacuation by senior staff. Hysterectomy required if cervix is gangrenous or generalized peritonitis exists.
• Hb Threshold: Hb $8\,g/dL$ is adequate for theatre evacuation if stable; others require transfusion to $10\,g/dL$.

Gestational Trophoblastic Disease (GTD)

• Hydatidiform Mole:
  • Diagnosis: "Grape-like" products or "snowstorm" ultrasound pattern.
  • Prep: Hb $< 9\,g/dL$ requires $2$ units transfusion. Avoid Misoprostol (causes excessive bleeding).
  • Evacuation: Use suction curette + Oxytocin infusion $10-20\,units/1\,L$.
• Follow-up:
  • hCG every $2$ weeks until $< 25\,Units/L$, then monthly for $1$ year.
  • Avoid pregnancy during follow-up as hCG is the marker.
• Chemotherapy (WHO Scoring): Score $0-4$ for low risk (single agent); $\ge 7$ for high risk (combination).

Termination of Pregnancy (TOP)

• Legality (Choice on TOP Act, 1996):
  • Up to $12$ weeks: On request.
  • $13-20$ weeks: Risk to mother/fetus, rape/incest, or socio-economic grounds (requires $1$ doctor).
  • After $20$ weeks: Endanger life, severe malformation, or injury to fetus (requires $2$ doctors).
• Medical Protocols:
  • $< 9$ weeks: Mifepristone $200\,mg$ PO, then $24-48$ hours later Misoprostol $800\,mcg$ PV.
  • $9-13$ weeks: Mifepristone $200\,mg$ PO, then $36-48$ hours later Misoprostol $800\,mcg$ PV + $400\,mcg$ every $3$ hours (max $4$ doses).
  • $13-20$ weeks: Misoprostol $600\,mcg$ PV loading, then $400\,mcg$ every $3$ hours (max $5$ doses).
• Anti-D: Give to Rh-negative patients ($250\,IU$ for 1st trimester; $625\,IU$ for 2nd).

Contraception and Sterilization

• Emergency Contraception: Ovral $2$ tablets, then $2$ more after $12$ hours (within $72$ hours of coitus). Copper IUCD can be used up to $7$ days post-coitus.
• Combined Oral Contraceptives (COC):
  • Missed pill ($> 12$ hours): Take missed pill, use precautions for next $7$ days. If within $7$ days of end of pack, skip pill-free interval.
• IUCD Insertion:
  • LMP must be known. Uterine sound used to measure depth. Cut threads to $2-3\,cm$.
  • Antibiotic cover: Doxycycline and Metronidazole for $5$ days.
• Sterilization: 18+ years only (unless life-threatening). Consent must emphasize permanence and small failure risk.

Abnormal Uterine Bleeding (AUB) and PALM COEIN

• Classification:
  • Structural (PALM): Polyp, Adenomyosis, Leiomyoma (Fibroid), Malignancy/Hyperplasia.
  • Non-Structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet specified.
• Medical Management:
  • Tranexamic acid (Cyclokapron): $0.5$ to $1\,g$ PO TDS for first $3$ days of flow. Reduces bleeding by $50\%$. Contraindicated in thromboembolism history.
  • Injectable Progestogens: Depo-Provera $150\,mg$ every $3$ months. Reduces bleeding by $95-100\%$.
  • Mirena (LNG-IUS): Reduces bleeding by $95-100\%$.
• Surgical: Myomectomy, Hysterectomy, Uterine Artery Embolization (UAE) (shrinks uterus by $50\%$), or High Intensity Focused Ultrasound (HIFU).

Endocrinology and Infertility

• Amenorrhea Definitions:
  • Primary: No menses by age $14$ (no secondary sexual characteristics) or age $16$ (present characteristics).
  • Secondary: Cessation for $6$ months.
• PCOS (Rotterdam Criteria): $2$ of $3$: Oligo/anovulation, polycystic ovaries on scan ($12+$ follicles, $2-10\,mm$), or hyperandrogenism.
• Hyperprolactinaemia: Prolactin $> 29\,ng/mL$. Bromocriptine ($1.25\,mg$ nocte, increasing gradually) or Cabergoline.
• Infertility: Failure to conceive after $1$ year.
  • Semen Analysis Norms (WHO): Volume $\ge 1.5\,ml$, Concentration $\ge 15\,million/ml$, Total motility $\ge 40\%$, Morphology $\ge 4\%$.

Oncology Protocols

• Cervical Cancer Staging (FIGO 2018):
  • Stage I: Confined to cervix ($Ia1 < 3\,mm$; $Ia2\,3-5\,mm$; $Ib1 < 2\,cm$; $Ib2\,2-4\,cm$; $Ib3 > 4\,cm$).
  • Stage II: Beyond uterus, no pelvic wall/lower 1/3 vagina ($2a1 < 4\,cm$; $2a2 > 4\,cm$; $2b$ parametria).
  • Stage III: Pelvic wall, lower 1/3 vagina, or hydronephrosis ($3c$ Positive nodes).
  • Stage IV: Bladder/rectum mucosa or distant spread.
• Management: Radical trachelectomy/Wertheim’s (Early stage) or Radiotherapy + Chemo (Advanced stage).
• Endometrial Cancer: TAH & BSO is the mainstay. Histological Grade $3$ has the worst prognosis.
• Ovarian Cancer: $\text{Risk of Malignancy Index (RMI)} = U \times M \times \text{CA-125}$. Standard treatment: Debulking + Platinum-based chemotherapy (Carboplatin/Taxol).

Urogynaecology and Surgical Complications

• Urinary Incontinence:
  • GSI: Treated with Kegel’s exercises or mid-urethral tapes (Obturator tape/TVT).
  • OAB (Detrusor Instability): Treated with Bladder Drill and Anticholinergics (Oxybutynin $2.5-5\,mg$).
• Uterine Perforation: Emergency requiring senior assistance. If bowel appears in os, immediate laparotomy is required. Use midline incision and inspect entire bowel.
• Post-operative DVT/PE:
  • Treatment: Clexane $80\,mg$ SC BD or Xarelto $15\,mg$ PO BD.
  • Prophylaxis: Clexane $40\,mg$ daily, mobilization, and hydration.