Cold Knife Cone Biopsy Counselling

Introduction:
Good morning, my name is ________________ and I am a final year medical student. Today, Ive
been asked to provide information about the procedure youre going for, and obtain informed
consent. May we proceed?

Ask: Name, Age, Marital Status, Children (if she has not completed her family, and wants to
maintain potential)

Instruction may be consent for Cold Knife biopsy, or counsel on CIN3.

Recap what is known:

So I understand you had some tests done and the result came back as CIN3. Do you understand
what that means? Well, CIN generally means that inside the cervix, there are precancerous cells
that can later become cervical cancer. They look abnormal on Pap smear and on Colposcopy. This
abnormality may be mild, moderate or severe, and when severe as in your case, we need to
intervene.

What has to be done?

This is where the Cone biopsy comes in. Cone biopsy involves removing part of the cervix where
the abnormal changes are and sending it to the lab so they can confirm. But at the same time,
we would have treated the problem, removing the precancerous cells.

Where is it done?
The Cone Biopsy is done in the operating theatre. Either they will put you general anesthesia so
that you will be asleep, or numb the area with a local anesthestic (para-cervical nerve cblock) so
you will be awake, but wont feel anything.

What preparation is needed?

Therefore, you will need to fast from 12pm the night before. You can only have clear fluids, such
as water.

What happens during the procedure?

At surgery, you will be in stirrups, and the surgeon will pass a speculum to visualize the cervix.
Then they remove the outermost part of the cervix, about 1 inch deep to get all the abnormal
cells. The procedure takes about 30 minutes in total, and would not require admission to the
ward.

Benefits:
This procedure is good when women with high grade abnormalities or early cervical cancer wants
to maintain their ability to have children. It is successful in up to 85-90% of patients.

Risks:
As with any surgical procedure, there may be possible risks. There may be risks with the
anaesthetics (allergy, apnea, high blood pressure) or with surgery, but these are minimal.

Early complications: pain, bleeding, infection

Late complications: preterm birth, scarring of the cervix, need for repeat
procedure/hysterectomy.

There is always a risk of infection or heavy bleeding which may require you to come back in
hospital for treatment. Sometimes, this type of surgery makes the cervix weaker, and may cause
preterm birth in future pregnancies. Sometimes the cervix doesnt heal well, leaving scars. Also,
there may be the need for a repeat procedure, if all of the abnormal cells were not removed, or if
there is recurrence. Women who have recurrence may consider a hysterectomy to remove the
entire womb, especially if they have completed their family.

After the Surgery:

After surgery, it is common to experience some mild pain and spotting for 2-3 weeks. It is also
recommended to avoid sexual intercourse, tampons or douching (not recommended at all) for 4-
6 weeks. It is important to maintain a healthy lifestyle, and avoid smoking, as this will help the
cervix heal properly.

Look out for:

You should come back into the emergency department in case there is any heavy bleeding fever,
pain in the abdomen, or foul smelling discharge from the uterus. Any of these may indicate a
possible complication.
Follow-up:
After the procedure, you will be allowed home with a clinic appointment in 1 week. I will also give
you a prescription for some painkillers and antibiotics. I will also provide you with some written
information, so you can read more about the procedure. I know I have done most of the talking,
but do you have any questions for me?

DISCUSSION:
ACTUAL INDICATIONS FOR CONE BIOPSY: (FROM BASSAWS BOOK)
Pap smear shows HGSIL, but equivocal colposcopy
Biopsy shows microinvasive disease (stage 1a), but this is not grossly apparent on
colposcopy
Cervical lesion cannot be fully visualised.

NB. If clinically evident tumour (Stage 1b), punch biopsy more suitable that cone biopsy, then
later surgery.

DIFFERENCES BETWEEN LEEP AND CONE BIOPSY:

NB. LEEP is done in office setting at the time of colposcopy, and uses local anesthesia. The
device uses electrical current to remove the outermost part of the cervix, and cauterise as it
goes, which prevents excessive bleeding. The size of the specimen, length of the procedure,
success rate, and degree of post-perative pain is almost the same as for a cold knife cone biopsy.

ANY OTHER OPTIONS:

Other options: Cryotherapy and Laser ablation, but these do not yield a tissue sample for
histology.
D&C Counselling
Introduction:
Good morning, my name is ________________ and I am a final year medical student. Today, Ive
been asked to provide information about the procedure youre going for, and obtain informed
consent. May we proceed?

Ask: Name, Age.

If indication is known, start by defining what is abnormal and why intervention is needed.

Recap what is known:

May be in reference to a diagnostic (diagnose AUB eg. endometrial hyperplasia, endometrial
cancer, endometrial polyps) or therapeutic indication (polypectomy, molar pregnancy,
miscarriage, retained placenta)

What has to be done?

This is where the D&C comes in. D&C is commonly known as scaping the womb. It is done to
remove tissue from inside the uterus. The tissue can then be sent to the lab to confirm the
diagnosis, or by removal, treat the problem.

Where is it done?
The D&C is done in the operating theatre. It is done under general anesthesia so that you will be
asleep during the procedure.

What preparation is needed?

Therefore, you will need to fast from 12pm the night before. You can only have clear fluids, such
as water.

What happens during the procedure?

At surgery, you will be in stirrups, and the surgeon will pass a speculum to visualize the cervix.
Then they will dilate the cervix slowly by inserting slender rods that progressively make the
opening larger. Then they will pass a thin instrument called a curette which has a sharp end that
does the scraping to remove the tissue. The procedure takes about 30 minutes in total, and you
would be able to go home after a few hours.

Hysteroscopy can also be performed at the same time to visualise the uterus for abnormalities.

Benefits:
It is a same day procedure and you would not need to stay overnight.

Risks:
As with any surgical procedure, there may be possible risks. There may be risks with the
anaesthetics (allergy, apnea, high blood pressure) or with surgery. During surgery, possible
complications include cervical tears during dilation, and perforation of the uterus, which is
making a hole through the uterus. This can be fixed at the same time by suturing the tear or hole
respectively, but these are rare.

Early complications: cervical tears/lacerations, uterine perforation, bleeding, infection.

Late complications: preterm birth, scarring of the cervix, need for repeat
procedure/hysterectomy.

Other complications include bleeding and infection. In rare cases, when too much scarping has
been done, adhesions form. Adhesions are bands of scar tissue inside the uterus. This condition
is called Asherman syndrome and may cause infertility and changes in menstrual flow, but can
be successfully treated with surgery.

After the Surgery:

After surgery, it is common to experience some mild pain and spotting for 2-3 weeks until the
new lining of the uterus has formed. It is recommended to avoid sexual intercourse, tampons or
douching (not recommended at all) for 4-6 weeks. Also, it is important to maintain a healthy
lifestyle, and avoid smoking, as this will help the uterus heal properly.

Look out for:

You should come back into the emergency department in case there is any heavy bleeding fever,
pain in the abdomen, or foul smelling discharge from the uterus. Any of these may indicate a
possible complication.

Follow-up:
After the procedure, you will be allowed home with a clinic appointment in 1 week. I will also give
you a prescription for some painkillers and antibiotics. I will also provide you with some written
information, so you can read more about the procedure. I know I have done most of the talking,
but do you have any questions for me?

INDICATIONS FOR D&C

DIAGNOSTIC:
Abnormal uterine bleeding: irregular bleeding, menorrhagia, suspected malignant or
premalignant condition
Retained material in the endometrial cavity
Evaluation of intracavitary findings from imaging procedures (polyps or fibroids)
Evaluation and removal of retained fluid from the endometrial cavity (hematometra,
pyometra)
Office endometrial biopsy insufficient for diagnosis or failed due to cervical stenosis
Endometrial sampling in conjunction with other procedures (eg, hysteroscopy,
laparoscopy)

THERAPUETIC
Miscarriage (eg, incomplete abortion, missed abortion, septic abortion, induced pregnancy
termination)
Treatment and evaluation of gestational trophoblastic disease
Hemorrhage unresponsive to hormone therapy (menorrhagia, dysmenorrhea)
In conjunction with endometrial ablation for histologic evaluation of the endometrium

CONTRAINDICATIONS FOR D&C

ABSOLUTE
Pregancy
Inability to visualize the cervical os
Obstructed vagina

RELATIVE
Severe cervical stenosis
Cervical/uterine anomalies
Prior endometrial ablation
Bleeding disorder
Acute pelvic infection (except to remove infected endometrial contents)
Obstructing cervical lesion

CAUSES OF AUB:
ANYTHING ELSE USED TO DILATE THE CERVIX?
Laminaria Tent is an osmotic agent that draws fluid from the cervix and swells, thereby dilating
the cervix.

Laparoscopic Sterilization
Introduction:
Good morning, my name is ________________ and I am a final year medical student. Today, Ive
been asked to provide information about the procedure youre going for, and obtain informed
consent. May we proceed?

Ask: Name, Age, Marital Status.

Get background information:

So I understand that you wish to undergo a sterilisation procedure, is that correct? I will just like
to ask a few questions before explaining what that is about:

When was your LNMP?

Do you have children? How old is your last child?
Why do you want to have this procedure done?

Disclaim: It should be noted that this procedure is permanent and for all intents and
purposes, irreversible.

Current pregnancy should be ruled out by asking LNMP. Ideal candidates for sterilisation are
those >30 years of age, who have completed their family. Patients may regret sterilisation often
if <30 years, or if done after a recent pregnancy.

Discuss the procedure:

There are different methods of sterilisation, and the one we will be doing is called
__________________________.

BTL: This procedure is done in the operating theatre under general anaesthesia, so you
will be asleep. It involves making a small cut in the bikini line, locating both tubes,
tying a loop of the tube and cutting the middle. Then, the cut is carefully sewn, so
that the scar is minimal. (Pomeroy method)

LAP: This procedure is done in the operating theatre under general anaesthesia, so you
will be asleep. A small cut is made under the navel, and a gas is used to inflate the
 abdomen so the surgeon has room to work and see everything. A camera
(laparoscope) is then inserted through that same cut to view inside. Another small
cut is made in the bikini line, and another instrument is inserted. This instrument is
used to apply clips on the tubes to block them (filshie clip applicator).

Once the tubes are cut / blocked, the egg would not be able to pass reach the womb, sperm
cannot reach the egg, and fertilisation is not possible.

What preparation is needed?

You will need to fast from 12pm the night before. You can only have clear fluids, such as water.

Risks:
As with any surgical procedure, there are risks involved. There may be risks with the
anaesthetics or with surgery such as bleeding, infection, damage to surrounding structures such
as bowel, bladder or blood vessels. In such cases, we may need to convert to a larger incision, to
repair. However these complications are rare.
Of concern, there is a risk of failure. The failure rate is 1 in 200, which means that 1 person out of
every 200 women who do this procedure will go on to become pregnant after. Furthermore, if
pregnancy does occur after, it is most likely going to be ectopic, that is, outside the womb.

Alternatives:
Keeping in mind those risks, it is my job to inform you about other possible long-term
contraceptive methods. One such method is the IUCD called Mirena, which can be inserted at the
neck of the womb, and is effective for 5-10 years. It is also reversible, so if ever there is a desire
to become pregnant, the Mirena can be easily removed.
Another possible option is Vasectomy, a procedure for your partner. What is good about
vasectomy is that is carries a much lower failure rate, 1 in 2000.

Myths:
There are several misconceptions about sterilisation. Female sterilization does not stop ovulation
or harm a womans egg in any way. An egg will still be released each month, but it will dissolve
and be reabsorbed by the body. It does not involve. No reproductive organs are removed, it
doesnt cause hormonal imbalances and sex drive is normal.

Conclusion:
Ok, so thats about it. I know we spoke about a lot, and I will provide you with some reading
material. Do you have any questions for me?

ARE THERE ANY BENEFITS OF STERILISATION?

May result in a lower risk for breast and ovarian cancer in the future.

CHECK GYNE BOOK PG 70/170 for further questions.