GYNECOLOGY

Before I go into the subject of what constitute an unsafe abortion, lets know what abortion itself is and if it is different from a miscarriage. Abortion is the termination or loss of pregnancy before the age of viability (the age at which the baby is capable of surviving outside the womb with or without life support) or the loss of an embryo or fetus that weigh less than 500g. The term abortion is often used interchangeably with miscarriage. However, women advocacy groups have faulted the use of both terms to mean the same. The term miscarriage is preferred as it is considered non-judgemental and not criminal as compared to the term abortion.  Abortion is now use to define induce abortion whether legal or criminal. While miscarriage is use to describe spontaneous termination of the pregnancy without any intervention.

Abortion is said to be unsafe when it is carried out by a person lacking the necessary skills, or in an environment lacking the minimum requirement to carry out the procedure. Abortion is legal when done within the confines of the law of the country, and criminal when done outside the stipulation of the law of the country. The law regulating abortion may vary between states in the same country; in Australia and the United States of America, abortion is legal in some states. Some countries have no restrictions like Canada and South Africa. Other countries like Nigeria and Egypt have the same restrictive laws in all states, only therapeutic abortion is allowed to save the mother.

THE CHALLENGES OF THE GYNAECOLOGIST IN A RESOURCE LIMITED SETTING

The annual unintended pregnancies globally were 121million between 2015 and 2019, which corresponds to 64 unintended pregnancies per 1000 women aged 15 to 49 years. 61% of unintended pregnancy ends in abortion, 73.3million abortions take place each year corresponding to 34 to 44 per 1000 women age 15-49years in the world [1]. 25million unsafe abortion occurred worldwide each year between 2010-2014 according to the World Health Organization (WHO). Abortion rates are higher in areas with unmet need for contraception. The WHO estimated that 47,000 women die from unsafe abortion each year.

The gynaecologists in resource poor settings face many challenges relating to abortion. Apart from the limited resources, another challenge is the restrictive abortion laws. A few patients have consulted me at the clinic because they want an abortion for reasons other than a threat to their lives by the pregnancy. The patients I have encountered were all married, they were at the right place but the law does not permit that. These patients do not have the opportunity to travel to other state as abortion laws in all the states in Nigeria are the same.

Whenever a woman walks out of my consulting room after a request for an abortion had been turned down, I get really worried. My fear is that she might not change her mind after counselling and might procure an abortion. I worry because it is likely to be an unsafe abortion because of the restrictive abortion laws. My experience with the outcome of patients at the emergency room with complications of unsafe abortion and low financial status is worrisome. They present late to us, often after 72hours and septic. While at surgery, their womb or womb with one or both ovaries will often appear gangrenous(decaying). Out of the four cases I have been directly involved in managing, only one of them survive. She went home after several weeks of battling infection and wound breakdown. She survived with only one ovary, the womb and the other ovary were gone.

The restrictive abortion laws never stop the abortions from happening, it only stopped many women from surviving to take care of their families. Most won’t make it because of their poor financial status. These I will say are avoidable deaths, they died from poor healthcare financing and the law.

REASONS FOR ABORTION

The reasons why women have abortion other than for therapeutic purpose include;

• Unwanted pregnancy
• Incest
• Pregnancy from rape
• Career decision
• Pregnancy with malformed babies

COMPLICATION OF UNSAFE ABORTION

• Injury to the genitals
• Perforation of the womb
• Injury to the intestines
• Infertility
• Infection
• Kidney failure from the overwhelming infection or massive blood loss necessitating dialysis
• Bleeding; necessitating blood transfusion and it attendant complications
• Gangrene (decomposition) of the womb and ovaries
• Premature menopause from the removal of the decaying ovaries
• Death

PREVENTION OF UNSAFE ABORTION

In a country with restrictive abortion laws, prevention of unsafe abortion and it complication starts with prevention of unwanted pregnancies. Though abstinence is the best prevention strategy, it is the most likely strategy to fail in this age of increased sexual awareness. To prevent unwanted pregnancies, women of reproductive age (15 to 49years) need to be enlightened on contraception. Though one can argue that even the most effective contraception does not provide hundred percent pregnancy prevention cover. So, what happen in that situation? I will say relax the restrictive laws. Improve health financing by government at all levels will go a long way. Making contraception available, accessible and affordable to women of reproductive age should be a must.

In my opinion, which is based on my experience in the field, relaxing the restrictive laws will save more women. They will have the opportunity to seek atonement for those who belief in the existence of God, many never had the chance, their deaths were avoidable.

If you know what to expect at hysterosalpingography(HSG) procedure, it will be better tolerated. Hysterosalpingography is a radiological investigation that is done using water soluble iodinated contrast or, iodinated oil to evaluate the cervix, womb and fallopian tubes.

INDICATIONS FOR HYSTEROSALPINGOGRAPHY

Hysterosalpingography might be requested by the gynaecologist in the following situation;

• Women who are unable to conceive.
• Women of reproductive age with abnormal menstrual bleeding like loss of menses when the woman is not pregnancy.
• Women with mid-trimester pregnancy loss suspected to be due to the inability of the cervix to hold pregnancy till maturity.
• Women with recurrent pregnancy loss from suspected abnormality of the womb.

CONTRA-INDICATIONS TO HYSTEROSALPINGOGRAPHY

HSG is not done in the following situation;

• Confirmed pregnancy
• During menses
• Recent uterine or tubal surgery
• Infection; HSG in the presence of active vaginal or cervical infection can result in transferring the offending pathogen into the upper genital tract and the pelvis.

WHEN SHOULD HYSTEROSALPINGOGRAPHY PROCEDURE BE DONE

The procedure is done after menses within the 6^th  to 12^th day from the first day of the menstrual flow. This period of the menstrual cycle is chosen for the procedure to avoid disrupting an ongoing pregnancy. Also, it gives better visualization of the cavity of the womb as the endometrium, the inner most layer of the womb, is thinnest at this time. Women who have lost their menses and are being evaluated for infertility, might be made to menstruate. The procedure can then be done at the stated time above. It can also be done for women who have lost their menses but have a negative result for pregnancy.

HYSTEROSALPINGOGRAPHY(HSG) PROCEDURE

Most women describe the hysterosalpingography(HSG) procedure to be extremely painful and dreadful. Why is that so? maybe they were not given pain medication. Thus, pain medication is required before the procedure. This can be given about 30 to 60minutes before the procedure. After changing into a procedure robe, an x-ray film called the scout film is taken while the woman is lying on the back (supine position). The patient is repositioned with the hip and knee bent and thighs apart. The vulva and vagina is cleaned with antiseptic solution. A plastic or metal instrument, speculum, will be inserted into the vagina. The speculum is open to expose the cervix. The cervix is also cleaned with antiseptic solution. Another instrument, catheter or cannula of appropriate size, will be inserted into the cervix. It is through this that the contrast will be injected slowly through the cervix, womb, fallopian tubes and into the pelvis. Then more x-ray films will be taken. Sometimes a repeat film can be taken if the first taken for a particular position is not good enough for interpretation.

INTERPRETATION OF HYSTEROSALPINGOGRAPHY FILM

The scout film is taken to serve as a reference film. The contrast is meant to outline the upper reproductive tract. If the contrast outlines the fallopian tubes and spills into the pelvis, the tubes are patent. When the contrast does not outline the fallopian tube; it is either tubal spasm or blockade. When the end of the contrast tapers into the tube but does not spill, it is tubal spasm. However, when the end of the contrast is rounded, it is tubal occlusion. The presence of fibroid or polyps in the womb will appear as a filling defect. The internal diameter of the cervix can also be measured. It will be dilated when the cervix is incompetent.

COMPLICATIONS OF HYSTEROSALPINGOGRAPHY

• Bleeding; this occur due to injury to the cervix by the instruments used
• Allergic reaction to contrast; might manifest as chills and rigor, wheals, confusion or even loss of consciousness. Do not worry as this is not very common. Even if it occurs, there are emergency medication in the procedure room to arrest the situation.
• Pain; this can occur during the procedure when the instruments are introduced into the genital tract or when the contrast is injected. After the procedure, pain can occur from uterine spasm. This is usually short live and can be taken care of by the use of pain medication. However, when this pain persists with associated fever and foul-smelly vaginal discharge then, you need to see the gynaecologist at the emergency room.
• Pelvic infection; this can result in pelvic inflammatory disease as the offending pathogen is introduce to the upper reproductive tract from the lower reproductive tract.
• Vasovagal reaction; manifest as fainting attack following manipulation of the cervix, insertion of the cannula or catheter.

There are several options for the medical treatment of uterine fibroid. However, the definitive treatment of uterine fibroid has been surgical. This has evolved over the years to include other non-surgical forms of treatments. Your doctor will take you through the various treatment modalities and help you arrive at that which is suitable for you. Medical treatment of myoma involve the use of certain classes of non-hormonal or hormonal medication to treat fibroid. This is not a definitive treatment as it only helps to reduce the symptoms and size of the fibroid. When treatment is stopped, the fibroid grows back. Medical treatment is indicated in the following situations;

• For symptomatic relief
• As an alternative to surgery in women who are near menopause, the fibroid usually shrinks at menopause due to lack of the hormone estrogen to fuel it growth.
• Where postponement of surgery is temporary
• As a pre- operative adjunct to reduce the size before surgery
• Patient that are not suitable for surgery
• Patient preference

NON HORMONAL MEDICAL TREATMENT OF UTERINE FIBROID

The prostagladin synthetase inhibitor class of medication include; mefenamic acid, ibuprofen and naproxen. It is used to treat heavy menstrual bleeding and painful menses. It is use daily throughout the period of menses starting from the onset or prior to onset of menses because it reduces blood loss and pain. Its use is not advisable in people with peptic ulcer disease and chronic kidney failure. Some side effects of this class of medication include: Gastritis, peptic ulceration, kidney failure.

The antifibrinolytic class of medication such as tranexamic acid is indicated for heavy menstrual bleeding. It is administered during menstruation for 5days to reduce blood loss. Its use is not advisable with concurrent use of combine oral contraceptives, history or an intrinsic risk for thromboembolism or allergic reaction to the medication. Its side effects include: thromboembolic event, impaired color vision, hypersensitivity reaction, nausea, vomiting, diarrhoea, abdominal pain.

The aromatase inhibitor class of medication include; letrozole and anastrazole. It is indicated for symptomatic treatment of myoma, use daily for 3months. It reduces the size of fibroid and blood loss during menses. This class of medication can cause profound reduction in estrogen which lead to menopausal symptoms and bone loss. If used for up to 6months, hormonal replacement therapy will be given to prevent causing premature menopause.

HORMONAL MEDICAL TREATMENT OF FIBROID

The gonadotropin releasing hormone agonist(GNRH) class of medication include: Leuprolide acetate (Lupron), Goserelin (Zoladex), Triptorelin (relstar). These injectable medications are given monthly or 3monthly for 3 to 6months. When used for more than 6months, hormonal replacement therapy is recommended due to its side effects. They act by down regulating the pituitary and suppress ovarian function. They have the advantage of reducing menstrual blood loss and may cause complete cessation of menses, improvement of anemia, relief of pressure symptoms by reduction in size of the fibroid, reduction in blood loss during surgery by reduction in the myoma blood supply and may facilitate the use of minimal access surgery such as laparoscopic or hysteroscopic surgeries. The disadvantages of the use of GnRH agonist include: menopausal symptoms (Vasomotor symptoms, trabecular bone loss), ovarian hyperstimulation, high cost, regrowth of myomas on cessation of therapy, degeneration in some myomas causing difficulty in removal during surgery.

The gonadotropin releasing hormone antagonist class of medication include: Ganirelix and Centrorelix. They are daily injectable and act by causing immediate suppression of the pituitary and the ovaries. They do not have the initial stimulatory effect like the GnRH agonist. Their benefits are same as that of agonists but it onset of cessation of menses is rapid. Have similar side effects with GnRH agonist.

The progesterone antagonist class of medication such as Mifepristone is recommended for 3 -6months.  It is effective in reducing fibroid size and heavy menses; it may cause complete cessation of menses. The drawbacks with its use includes: vasomotor symptoms such as hot flushes and feeling of one’s heart beats called palpitation and endometrial hyperplasia which is the thickening of the inner lining of the womb.

The selective progesterone receptor modulator class of medication such as the ulipristal acetate has similar effects to mifepristone. It is given orally daily for 12weeks. It reduces bleeding and fibroid size. The drawback with its use is that it causes endometrial hyperplasia.

The progesterone class of medication which include: Noresthisterone acetate, Depo-Medroxyprogesterone acetate, or Medroxyprogesterone acetate. They reduce blood loss and are used during acute bleeding then tapered down when bleeding reduce. The Levonorgestrel-releasing Intrauterine System (LNG-IUS) is inserted into the womb. It reduces blood loss and uterine size however, it is not recommended when the uterine size is >12 weeks or there is distortion of uterine cavity and has limited use in patient who do not desire contraception. Their side effects include: muscle and joint pain, breast pain, headache.

The androgen class of medication such as danazol administer daily or gestrinone administer twice weekly reduce blood loss and fibroid size. They may cause cessation of menses. Their side effects include: hirsutism, oily skin, acne, weight gain, voice change. Their use is limited only for a period of 3–6 months.

Though not applicable to all patients medical treatment of fibroid may obviate the need for surgery and it complications.

The non medical treatment of uterine fibroid is either surgical or radiologic. The surgical options of treatment for fibroid include; hysterectomy, myomectomy, endometrial ablation and myolysis. The radiologic options include; uterine artery embolization and Magnetic Resonance-guided high intensity focused ultrasound. Patient who are not fit to undergo surgery can be offered medical treatment while they are been optimize.

NON MEDICAL TREATMENT OF UTERINE FIBROID- SURGICAL

Myolysis is a procedure which incite death of the fibroid tissue by the application of heat (electrocautery) or extreme cold (cryotherapy) to the fibroid.

Endometrial ablation involves the removal or destruction of the inner lining of the womb called the endometrium. This is done via the vaginal route and meant for fibroid in the inner lining of the womb called submucous fibroid. This also help to treat heavy menses due to the fibroid in that location. The procedure makes use of heat energy, microwave and cryosurgery (extreme cold).

Hysterectomy is the definitive treatment for fibroid, it is considered for women who no longer want more children. It involves removal of the womb. This is done in the operating room under anaesthesia. It can be done through the abdomen or by minimal access surgery called laparoscopy. The laparoscopic approach is costlier but is associated with less pain and short hospital stay after surgery. The abdominal route is associated with longer hospital stay about 3 to 5days. The possible complications of hysterectomy include; damage to the bladder, ureter, gut, excessive bleeding necessitating blood transfusion and complication of anaesthesia.

Myomectomy is a fertility preserving surgery for fibroid where the fibroid tissue is removed from the womb. The approach use depends on the location, size and number of the fibroid. The common approach use is the open abdominal approach as fibroid in all location can be reached. The vaginal approach by hysteroscopy is meant for fibroid in the cavity of the womb. The laparoscopic approach is for fibroid in the outer and muscle layers of the womb. Large size and high number of fibroid in the womb limit the use of the laparoscopic approach. Complication of myomectomy include adhesion formation and recurrence; the recurrence is from very small seedlings that could not be seen during the surgery.

PREGNANCY AFTER MYOMECTOMY

After removal of fibroid, it is advisable to wait three to six months before attempting to get pregnant. For some women who are unable to conceive with fibroid, removal of the fibroid increase the chance of pregnancy. Fibroid removal operation is considered a scar on the womb similar to that of caesarean section. When the removal is considered extensive or when the endometrium is bridged, delivery in the next pregnancy should be by caesarean section as vaginal delivery is associated with rupture of the womb. Do well to remember this after the post operation briefing. You might not have your antenatal care in the same facility where the operation was done. Do not forget to inform your doctor if you were told your fibroid removal was extensive or the endometrium was bridged.

UTERINE ARTERY EMBOLIZATION(UAE)

This is an interventional radiologic procedure that delivers certain material into both uterine arteries. The procedure involves passing a device call a catheter into the femoral artery which is then directed into the uterine artery before introducing a substance that will block blood flow. Sealing the uterine artery blood flow result in blockade of blood supply to the fibroid. This will result in the death of the fibroid tissue thereby reducing the fibroid size.  Women whose symptoms persist significantly with medical treatment will benefit from UAE where available. A myomectomy or hysterectomy were applicable is considered where UAE is not feasible.

Before UAE, a thorough evaluation will be carried out to rule out the possibility of cervical cancer, endometrial cancer and sexually transmitted infections such as gonorrhea and chlamydia.There are reports of patient satisfaction with UAE and symptom improvement compared with myomectomy and hysterectomy. The challenge with this is the non-availability of experts skilled in this procedure in certain region or countries. Where there are experts, the equipment to perform it might not be available. After the procedure, admission for a day or two might be necessary.

ABSOLUTE CONTRAINDICATIONS TO UAE

• Pregnancy
• Active uterine or adnexal infection
• Suspected reproductive tract cancer; cervical or endometrial cancer

RELATIVE CONTRAINDICATIONS TO UAE                                                                  

• Coagulopathy (abnormality of blood clot formation)                                                                        
• Renal impairment.                                                       
• Severe contrast allergy.                                            
• Desire for future fertility
• Uterine size >20–24 weeks                                      
• Prior salpingectomy or salpingo-ophorectomy (removal of the fallopian tubes or both tubes and ovaries)                                     
• Prior pelvic radiation                                                
• Large hydrosalpinx: fluid in the fallopian tube.                                                    
• GnRH agonist use

COMPLICATIONS OF UAE

• Post embolization syndrome; this is characterized by malaise, fever, nausea and pelvic pain.
• Groin hematoma
• Permanent loss of menses
• Subsequent Pregnancy complication
• Rarely necrosis of the uterus, adnexa and bladder
• Some patients will require subsequent procedure

MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND

This is also called Magnetic Resonance-guided high intensity focused ultrasound (MR-HIFU). It involves the use of ultrasound energy which is focused to heat and incite tissue death in selected myomas. Concurrent Magnetic Resonance imaging enables precise targeting and provides real-time tissue temperature feedback to prevent heat injury to the surrounding tissues. A session can last for 2 to 3hours. A urethral catheter will also be pass for continuous emptying of the bladder. The major challenge is the non-availability of resources in certain regions and countries in term of skill and equipment. The selection criteria for patient include;

• fibroid size 4-10cm,
• completed family size
• perimenopausal.

CONTRAINDICATIONS TO MRgFUS

• Pregnancy
• Energy path obstructions such as abdominal wall scars or foreign bodies
• Future fertility desires
• Current pelvic infection
• Other uterine pathology
• Menopause
• Myoma size >10 cm, and uterine size >24 weeks.

ADVANTAGES OF MRgFUS

•   Noninvasive
•   Requires only conscious sedation
•   Rapid recovery and return to daily activities

DISADVANTAGES OF MRgFUS

•   Symptoms relief wanes with time, and
•   Some patient might seek alternative procedures for their symptoms, including hysterectomy.

COMPLICATIONS OF MRgFUS

• Skin burn
• Adjacent tissue injury
• venous thromboembolism.

Before I begin, I will like to correct a misinformation about uterine fibroid treatment; that it can be pass in stool. This is not true whatever be the treatment modality. It is very important to know that no medication or intervention can make one pass fibroid in stool. There is no anatomic connection between the reproductive and digestive system.

Uterine fibroid also known as leiomyoma or myoma is a benign smooth muscle neoplasm arising from the myometrium. In simple terms, an abnormal growth of some muscle cells in the womb. The myometrium is the second layer of the womb made up of smooth muscle. The true incidence is unknown as many women do not have symptoms.

CAUSES OF UTERINE FIBROID

How uterine fibroids come to be is poorly understood however, it is common in female of reproductive age (15 to 49years) with the following risk factors;

•  High estrogen state: age at first menses <10years, polycystic ovarian syndrome, obesity.
• Nulliparity (no child birth)
• Black women
• High fat diet
• Family history in first degree relative
• Late menopause
• Alcohol. 

The following are protective factors for myoma formation:

• Smoking
• Exercise
• Increased number of children
• Late menarche (late onset of first menses)
• Early menopause
• Use of oral contraceptive

SIGNS AND SYMPTOMS OF UTERINE FIBROID

The clinically presentation of this condition varies from asymptomatic to symptomatic. These symptoms include;

• Menstrual abnormalities: heavy menstrual bleeding, intermenstrual bleeding
• Painful menses
• Pain during sexual intercourse
• Pelvic pain
• Abdominal swelling
• Pressure symptoms: frequent urination, urinary retention, constipation

COMPLICATION OF UTERINE FIBROID

 Some may present with complications such as;

• Infertility
• Anaemia
• Obstructive uropathy; injury to the kidney from the blockage of urine flow
• Venous thrombo-embolism; formation of blood clot in the vein
• Abdominal pain in pregnancy

CHANGES IN UTERINE FIBROID

The size or composition of a fibroid changes with time due to hormonal influence. These changes are called secondary changes and they include; some degenerative changes such as hyaline degeneration which is the most common, cystic, fatty and calcific degeneration that occurs at menopause, red degeneration occurs in pregnancy. Other changes are atrophy, necrosis, infection, vascular changes and it may become a cancer in <0.1% of the cases.

LOCATION OF FIBROID

Leiomyoma based on their location in relation to the uterus can be classified into;

• Sub-mucous Leiomyoma; arise from the smooth muscle close to the endometrium which is the inner layer of the womb.
•  Intramural leiomyoma; arise within the myometrium which is the muscle layer of the womb
• Sub-serous leiomyoma; arise from the smooth muscle adjacent to the serosa of the uterus. The serosa is the outer covering of the womb
• Other variants are the pedunculated leiomyoma; which is attached by a stalk to the womb. The parasitic leiomyoma is a pedunculated fibroid that attaches itself to nearby pelvic structures where it gets it blood supply.

DIAGNOSING UTERINE FIBROID

Uterine fibroid can be diagnosed from the clinical presentation and findings on pelvic examination; firm mobile or slightly mobile, uniform or nodular pelvic mass. Hysteroscopy and hysterosalpingography will confirmed the presence of a sub-mucous fibroid and also define tubal patency. Ultrasonography will confirm the fibroid in any location with associated secondary changes and complication. If still in doubt, magnetic resonance imaging can distinguish fibroid from adenomyosis; when the endometrial or inner lining of the womb is implanted in the muscle layer.

TREATMENT OF UTERINE FIBROID

The management of uterine myoma depends on the size, number, location of the fibroid, age of the woman and the desire for fertility. This could be expectant (indicated when patient is asymptomatic with fibroid size <12weeks), surgical (myomectomy, endometrial ablation, myolysis and hysterectomy) or non-surgical (medical or interventional radiology).

Medical treatment is indicated for symptomatic patient. It is an alternative to surgery in perimenopausal women. It is also a pre-operative adjunct and for patient not suitable for surgery. This could be by the use of non-hormonal agents (Aromatase inhibitor, antifibrinolytic and non-steroidal anti-inflammatory drugs), or hormonal agents (gonadotrophin releasing hormone antagonist, progesterone antagonist, progesterone therapy, selective progesterone reception modulator and androgen therapy). Interventional radiology involves the use of uterine artery embolization and magnetic resonance-guided focused ultrasound scan.

For women with persistent symptoms despite conservative efforts, surgical management is an option. Myomectomy which could be laparoscopic, hysteroscopic or open is the most common fertility preserving surgery for women who desire fertility and hysterectomy a non-fertility conserving surgery is the definitive treatment.

EXPECTANT TREATMENT

No intervention or medication is given here but periodic examination at interval of 6 months is carried out. If the symptoms of fibroid appear and or it grows and increases in size, expectant management will be abandoned. Before contemplating expectant management, a certain diagnosis of fibroid should be a must. Other indications for expectant management includes;

• Size of the womb <12 weeks (of pregnancy size)
• Asymptomatic
• Follow up is possible