You are currently browsing the Dr Licciardi blog archives for August, 2006.

Diagnostic Laparoscopy

This means a laparoscopy that is scheduled to “look for things”. There is no reason outside of infertility to do the procedure.
I rarely perform a diagnostic laparoscopy. Why? Because I got tired of doing them and finding nothing. As I consider diagnostic laparoscopy, I think about the information I already have. Is the ultrasound completely normal? Is there a history of pelvic infection? Is there a history of pelvic pain? Is there a history of pelvic surgery? Is the hysterogram normal? Some doctors will do a blood test for Chlamydia to see if there was a past history of that infection.
If the answer to all of these questions is no, the odds of finding something on laparoscopy is very low. Some reports say it’s about 5%. Before the comments come pouring in there are a few things to add. First, a small amount of endometriosis will be identified in some patients, but in most of those cases, it’s not enough to shake a stick at, and the laparoscopy will have been unnecessary. Second, there will always be surprise cases, where pre-op everything was negative, and at surgery there are adhesions and or endometriosis. I question some of these cases. Were the pre-op tests reviewed carefully enough? For example, a cyst of endometriosis(endometrioma) should be seen on the pre-op ultrasound. Some of the cases are unquestionable; all was negative but the surgery showed correctable findings. So here is the balance question. Do many patients have unnecessary surgery to find problems in a very few? If a diagnostic laparoscopy was recommended to you, be sure to go over these issues with your doctor. Even a simple laparoscopy can have unfortunate complications. It’s not minor surgery.

References:

The Boxes of Pregnancy and Miscarriage

When a pregnancy finally happens, a box inside our mind opens up. We have a number of boxes in our heads, but one of the very unique boxes is for pregnancy. It’s filled with positive thoughts that are infused with a feeling of confidence. The words “everything will be OK”, frequently come to mind. Memories of past mistakes don’t seem as painful as they did before the pregnancy. In fact, memories of all bad things gone by become muted by the vast open space of optimism that pregnancy promotes. It’s full steam ahead, don’t look back, and the sky is the limit. Pregnancy becomes the great equalizer.

No matter the differences in life experiences between two people, if you’re both pregnant you’re both in the same boat. You have become the owner of a new possession, the best possession, the only true possession. There is a new sense of security and completeness. Everything is OK, and real problems will have a way of working themselves out. We think of loved ones and how happy they will be with news.
And then comes the miscarriage. So where does that leave us? To start, scratch the above, the pregnancy box closes completely immediately. And the rest? Well the emotions don’t flip. We don’t suddenly lose all confidence and become phobic and pessimistic. In fact, we always knew miscarriage was a distinct possibility and now that it happened we deal with it like many other negatives that came before. But what we are not ready for is dealing with the concept of loss. Loss is the other very unique box, and when it’s opened, we are joined by every other loss we have had. And our reaction to the loss is as it would be for any other loss.

It’s sad and overwhelming and impossible to control. But, as with the other losses, most of us do get through it, some more quickly than others. Some have the opportunity to try again, some knew this was the last chance and it’s over forever. So with time we recover and this box too will close, albeit more slowly than we would like.

Abnormal Bleeding? Don’t have a D and C without a Hysteroscopy (and have an ultrasound first)

I just left the operating room where I was performing surgery on a patient who didn’t need it.
The woman is a 48 y.o. with a bunch of kids who had developed very heavy vaginal bleeding over the past few months. So what did her gynecologist do? He did a D&C(dilatation and curettage).
The dilation and curettage procedure is called a D&C. The D stands for dilation, which means enlarging. Curettage (the C) means scraping. Together, this procedure involves expanding or enlarging the entrance of a woman’s uterus so that a thin, sharp instrument can scrape or suction away the lining of the uterus and take tissue samples. (from e medicine). It’s similar to the procedure a woman may have for a miscarriage.
Guess what? The D and C had no effect on her bleeding and she called me for a second opinion. My questions to her were, did they do an ultrasound before the procedure and did they look inside the uterus with a scope at the time of the D and C (hysteroscopy)? The answer to both were no. I could not believe that in this day and age, things were still performed in such an archaic fashion. An ultrasound can give the doctor a better idea of what the problem really is. A D&C without a hysteroscopy is like bobbing for apples blindfolded. The hysteroscope allows us look directly inside the uterus to look for common problems such as polyps and fibroids (another blog). If we just try to scrape the lining of the uterus, polyps may get swept from side to side but not removed, and fibroids are too firm to be scrapped away. When these items are seen on hysteroscopy, instruments can be used to remove them under direct visualization, a much more accurate way of doing things. Hysterosopcy in not necessary during a D&C for miscarriage.

So this lovely woman needed me to give her a second procedure with another anesthesia. My pre-op ultrasound showed a polyp, which was seen and removed at the hysteroscopy. All went well, and this problem should be solved.
And dont forget, see post 5/17/06.

References:

  • March CM. Management of Asherman’s syndrome. Reprod Biomed Online. 2011 Jul; 23(1):63-76.
  • Tuuli MG, Shanks A, Bernhard L, Odibo AO, Macones GA, Cahill A. Uterine synechiae and pregnancy complications. Obstet Gynecol. 2012 Apr; 119(4):810-4.
  • Cooper JM, Houck RM, Rigberg HS. The incidence of intrauterine abnormalities found at hysteroscopy in patients undergoing elective hysteroscopic sterilization. J Reprod Med. 1983 Oct; 28(10):659-61.