Covid 19 and Gynaecological Services at NMH

The impact of COVID-19 upon Maternity and Gynaecologic services has been immense. As the pandemic approached Ireland, infrastructural changes within the NMH were planned and completed promptly to optimise physical distancing arrangements in clinical areas and allow for isolation of suspected cases. To date these measures have been very effective in reducing the risk of person to person transmission of the virus SARS-CoV-2 which causes COVID 19 among staff and patients.  They have facilitated the best practice in the management of our sickest patients to date with all patients having excellent outcomes.

The burden of redeploying our physical and human resources is particularly significant in Gynaecologic services. It has been necessary to defer face to face consultations in many instances, and elective procedures for benign disease have been deferred until further notice. As far as possible, remote communication with patients occurs in lieu of out-patient attendance, and administration staff will reschedule visits in due course. Cases where there is suspicion of malignancy continue to be managed urgently, and out-patient procedures in hysteroscopy, tissue biopsy, colposcopy etc., remain functional. For the time being however, cases deemed to be non-life-threatening continue to experience delay in accessing the full range of secondary care.

We believe that this pause is the least damaging approach in a time of crisis, where choice is limited and unpalatable options are the reality.

We understand the distress and disruption this situation is causing on patients and also on the GP community looking after them. The NMH team will continue to triage Gynaecology referrals and plan for phased escalation of the service as soon as is safe and possible to do so. In the meantime, we hope the following recommendations for the care of women with some of the following common problems will prove helpful.

ABNORMAL UTERINE BLEEDING

ABNORMAL UTERINE BLEEDING

Abnormal uterine bleeding is a common reason for Gynaecologic referral. The majority of causes are benign, but some cases raise concerns about gynaecological cancer. It can be broadly divided into the following:

  • Menorrhagia (regular heavy menstrual bleeding)
  • inter-menstrual bleeding
  • postmenopausal bleeding
  • post coital bleeding

 

Menorrhagia

Women with regular heavy menstrual bleeding should initially be managed by remote communication. They should be reassured that the complaint is common and that the risk of malignancy is very low.

  • History should describe the severity of the symptoms, the possibility of anaemia and the likely cause.
  • If there are no significant symptoms of anaemia, medication should be prescribed with due consideration of relevant contraindications (NICE guidelines)
  • Women should be referred to secondary care for further management if:
    • Bleeding is torrential and / or prolonged.
    • Bleeding is ongoing and unmanageable despite recommended oral treatments
    • Significant anaemia is suspected.

 

Women being referred to secondary care should have the following examination and investigations included with the referral:

  • A pelvic examination
  • A full blood count to diagnose anaemia.
  • If locally available, a pelvic ultrasound / other recent imaging reports

 

Consider the following interim therapies for women being referred to secondary care:

  • oral or intravenous iron infusion according to the severity of the anaemia and associated symptoms.
  • Tranexamic acid and a course of high dose oral progestogens to rapidly supress acute bleeding.
  • NICE recommended medical treatments that have not been used including the levonorgesterol- releasing intrauterine system.
  • Gonadotrophin releasing hormone (GnRH) analogues for refractory bleeding despite use of recommended NICE medical treatments and / or in the presence of significant uterine fibroids. This is a high-tech prescription so would need to be organised in conjunction with hospital clinic. Consider moving to a 3-month duration injection once patient tolerance of GnRH analogues has been established or delivery via the nasal route. Addback hormone replacement therapy (HRT) should be considered, once bleeding is controlled if GnRH analogue treatment is to be continued beyond 3-6 months.

 

Intermenstrual Bleeding

Women with IMB should initially be managed by remote communication. Women should be reassured that IMB is common and symptoms often spontaneously resolve and that underlying cancer is rare.

A relevant clinical history should describe the severity of the symptoms and enquire about the likely cause:

  • Cervical smear history
  • Use of hormonal preparations
  • Pregnancy should be excluded
  • Likelihood of STI

Where the likelihood of sexually transmitted infection or genital tract cancer is considered negligible, then management options to discuss include:

  • Reassurance.
  • Observation with phone follow up to see if the IMB subsides.
  • Change in hormonal contraceptives in current users.
  • Trial of hormonal contraceptives in non-users.

Women should be asked to come for a pelvic examination, preferably in primary care, if:

  • There is a risk of sexually transmitted infection (take genital tract swabs).
  • Cervical cancer is suspected because of associated post-coital bleeding and / or offensive vaginal discharge.

Women should be referred to secondary care for further investigation of IMB if:

  • Cervical cancer is suspected on pelvic examination.
  • Endometrial cancer is suspected because of persistent IMB (i.e. occurring for at least 3 consecutive months) in women over 40 years who are not using hormonal contraceptives.

 

Post-menopausal bleeding

Referrals for PMB will be triaged urgently and an individualised plan of action made taking into account additional risk factors for malignancy, and whether hospital attendance should be deferred for COVID vulnerable individuals eg., those cocooning, or currently in self-isolation.

Women presenting with postmenopausal bleeding will firstly have a pelvic ultrasound to determine endometrial thickness. The scan report is reviewed by a consultant and a decision is then made regarding the need for hysteroscopy / tissue sampling. It would be helpful to include information such as smear history, HRT use, pelvic examination findings and BMI. If for any reason you feel the patient would not be suitable for a transvaginal scan or outpatient hysteroscopy please let us know.

 

Post coital bleeding

Women with PCB should initially be managed by remote communication. If they have an in-date negative cervical screening test, a cervical cancer is extremely unlikely and patients should be reassured.

Women with PCB who do not have an in-date negative cervical screening test need to be seen for a speculum examination and for a smear to be taken.

If they have any risk factors for a sexually transmitted disease, they should have genital tract swabs taken or referred to a Sexual Health Clinic for further investigation and management.

OVARIAN CYSTS

OVARIAN CYSTS

Referrals for ovarian cysts will be triaged according to symptomatology and risk of malignancy. Lesions suspicious for ovarian cancer will be managed urgently by the Gynaecology Oncology Specialists.

CA125 and transvaginal ultrasound scan findings should be included in referrals, as well as significant personal or family history (ovarian, bowel or breast cancer).

The RMI score (malignancy risk index) is calculated based on the serum CA 125 value, menopausal status (M), and evaluation of ultrasound (U).

 RMI = U x M x s-CA 125

Ultrasound features (U)

Multilocular cyst  1
Solid areas 1
Bilateral lesions  1
Ascites 1
Metastases 1

Menopausal Status (M)

Premenopause 1
Postmenopause 3

In general, lesions with RMI > 200 have a high index of suspicion for cancer.

Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. In the presence of normal serum CA125 levels, these cysts can be managed conservatively, with a repeat evaluation in 4–6 months.

UROGYNAECOLOGY

UROGYNAECOLOGY

Most patients seen in Urogynaecology clinics present with non-urgent conditions such as prolapse and/or incontinence. Rarely do they require emergency admission to hospital. A significant proportion are over 60 years of age making them more vulnerable to Covid 19 disease and therefore important to keep protected from hospital exposure.

Women with vaginal pessaries who would have attended for regular follow up in the urogynaecology clinic will have telephone consultations in the first instance. Most can be reassured that a slight delay of a few months to the pessary change will have no harmful effects. Presciptions for vaginal oestrogen preparations can be posted out.

A number of selected patients have been contacted to attend Dr Keane’s clinic in the coming weeks, and these attendances will take place for with strict adherence to physical distancing restrictions.

 

Urologic Emergencies 

  • Urinary retention – urgent. Phone ahead to be seen in ED 

Patients presenting with urinary retention (postnatally or otherwise) if newly diagnosed need an urgent review to prevent bladder injury. It may be possible to see these patients within a gynaecology/ postnatal ward where nurses/midwives are trained to catheterise patients and monitor residual urine. If the patient has any risk factors for COVID 19, arrangements can be made for ED staff in PPE to meet the patient and bring to isolation area directly.

The initial management will usually be with an indwelling catheter with a review in a week for a Trial Without Catheter (TWOC).

  • Fistulation from a pessary

Severe problems arising from a pessary left in situ are relatively rare. When they occur it is usually in relation to Gelhorn and shelf pessaries. When this occurs, an urgent review appointment will be arranged.

If a pessary is causing problems such as bleeding, pain or ulceration, patients may be asked to attend for a face to face consultation, provided they are not symptomatic for Covid or in an extremely vulnerable group. Post-menopausal bleeding in women with intact uterus and a vaginal pessary for prolapse will be triaged in line with the hospital’s PMB pathway.

FERTILITY

FERTILITY

  • Delay in fertility investigation and management is the cause of significant anxiety and distress among patients, compounding that already caused by the condition.
  • Face to face out-patient consultations for infertility have been deferred during the pandemic.  Telephone consultations will continue to occur as much as possible, and follow-up appointments will be scheduled as soon as possible.
  • The suspension of Assisted Reproduction Treatment on advice by ESHRE at the beginning of the European pandemic has been recently revised so that ART clinics can resume treatment cycles. Merrion Fertility Clinic is continuing to manage patients remotely and plan for treatments under restricted conditions.
  • Patients who need to undergo fertility preservation ahead of cancer therapy will be managed urgently.
  • Patients who are trying to conceive naturally should be reassured about the lack of evidence of negative effects of SARS-COV2 in early pregnancy. There are no guidelines advising against conception during this time. All patients should be advised on healthy lifestyle, folic acid and vitamin D supplementation.
RECURRING 1ST TRIMESTER / 2ND TRIMESTER MISCARRIAGE

RECURRING MISCARRIAGE / 2ND TRIMESTER LOSS CLINIC

  • Patients attending NMH who are diagnosed with a 3rd consecutive early miscarriage or a second trimester loss will be automatically referred for timed investigations and subsequent remote clinic review by Dr Allen.
  • Referrals from GPs will be triaged and patients fulfilling the criteria will be contacted by the bereavement liaison midwife team. Arrangements will be made for blood and ultrasound investigations to take place, and for subsequent clinic review to occur remotely.
  • Patients who have previously attended this clinic will already have a care plan for future pregnancy. In the event of a positive pregnancy test, they should follow the advice in their plan to contact the bereavement liaison midwife team who will arrange early pregnancy assessment, any necessary additional prescriptions, and first trimester surveillance with Dr Allen in the antenatal out-patient clinic.
  • It is not possible at present to provide a second opinion on tests performed in other units.
CHRONIC PELVIC PAIN

CHRONIC PELVIC PAIN

The multifactorial nature of CPP makes it difficult to triage but as a general rule patients presenting for the first time in later life and those with atypical symptoms normally warrant hospital referral.

Women should be offered appropriate analgesia to control their pain even if no other therapeutic manoeuvres are yet to be initiated.

Known or suspected cases of endometriosis:

Pelvic pain which varies markedly over the menstrual cycle is likely to be attributable to a hormonally driven condition such as endometriosis. Options for management for suspected but unconfirmed cases while awaiting Gynaecology assessment include the following:

  • Continuous course of combined oral contraceptive eg tricyling for 3/12, for patients without contraindications.
  •  progesterone-only pill
  • oral progestogens daily
  • Some patients get relief with insertion of levonorgesterol- releasing intrauterine system.
  • Gonadotrophin releasing hormone (GnRH) analogues for management of severe pain despite medical treatments in conjunction with remote hospital clinic. Consider moving to a 3-month duration injection once patient tolerance of GnRH analogues has been established. Addback hormone replacement therapy (HRT) should be considered, once pain is controlled if GnRH analogue treatment is to be continued beyond 3-6 months.

Irritable bowel syndrome

www.bsg.org.uk provides guidance on management of IBS and may be useful in elucidating and alleviating symptoms of pelvic pain in patients with a normal gynaecologic examination.

Women with IBS should be offered a trial with antispasmodics. Women with IBS should be encouraged to amend their diet to attempt to control symptoms.

  • Certain symptoms are considered ‘red flag’ and should be highlighted in referrals for CPP
  • Bleeding per rectum
  • New bowel symptoms over 50 years of age
  • New pain after the menopause
  • Pelvic mass
  • Suicidal ideation
  • Excessive weight loss
  • Irregular vaginal bleeding over 40 years of age
  • Postcoital bleeding

Suspected Pelvic Inflammatory Disease

All sexually active women with chronic pelvic pain should be offered screening for sexually transmitted infections (STIs). Suitable samples to screen for infection, particularly Chlamydia trachomatis and gonorrhoea, should be taken if there is any suspicion of PID.

If PID is suspected clinically, this condition is best managed in conjunction with a genitourinary medicine service in order that up-to-date microbiological advice and contact tracing can be arranged.

ADOLESCENT GYNAECOLOGY

ADOLESCENT GYNAECOLOGY

While serious gynaecological pathology in childhood and adolesence is rare, we appreciate that gynaecological symptoms can cause significant distress, in particular to those students studying for upcoming examinations.

In so far as possible we are offering telephone consultations with parents and young women.

Urgent referrals will be reviewed and it may be possible to offer advice remotely.

The majority of adolescents attending our clinics do so because of menstrual problems. Menstrual problems are very common in adolescents and are mostly related to anovulatory cycles.

We would recommend continuing current treatments such as the Combined Oral Contraceptive pill if the treatment is working well.

It is helpful to keep a menstrual/symptom diary/app.

Helpful regimens for menstrual problems include:

Non-steroidal anti-inflammatory drugs:

Ibuprofen 10mg/kg max 400mg TDS, or Mefenamic acid 500mg TDS >12 years.
Decrease in blood loss by approximately 20% as evidenced by Cochrane

Emphasize the importance of early commencement of regular analgesia.

Tranexamic Acid1g QDS (500mg QDS if <50 kg)   — 40-50% ↓in menstrual flow v placebo Cochrane

Hormonal management:
Cyclical progesterone is particularly helpful for younger girls who do not need contraception.
Norethisterone 5 mg BD-TDS Day Day 14- 28
Duphaston 10 mg bd daily Day 14-28 – continue x 6/12
Medroxyprogesterone Acetate
2.5-10 mg od Day 14- 28

30mcg COCP usually gives better cycle control than 20 mcg Pills. Extended use/back to back COCP is particularly effective for management of cyclical symptoms. Breakthrough bleeding may occur when taking the pill in this manner. A 4-day break may be necessary if there is breakthrough bleeding for more than 4 days.

LARCS may be appropriate for some adolescents.

See britspag.org for useful  patient information leaflets on common adolescent gynaecological conditions.

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