GY Gynecologic Procedures This chapter deals primarily with APGO Educa EEREAEY Gynecological Procedures Evaluation and management of gynecologic problems frequently require performing diagnostic and ther- apeutic surgical procedures. Understanding the risks and benefits of such procedures is important in coun- seling patients about their treatment options and the reasons for having the procedures performed. IMAGING STUDIES ‘Gynecologic imaging plays an important role in the diag- nostic evaluation of women for a variety of reproductive health conditions. Although the ability to image various parts and organs of the body has dramatically enhanced clinicians’ diagnostic capabilities, these methods do not replacea careful and thoughtful history and physical eval- uation, However, they can add more detail, which assists in both medical and surgical management. The effective use ofthese modalities requires that the physician be famil- iar with the benefits and limitations of each method. Ultrasonography Ultrasonography remains the most common modality for evaluation of the female pelvis. It uses high-frequency sound reflections to identify different body tissues and structures. Shore bursts of low-energy sound wavesare sent into the body. When these waves encounter the interface between two tissues that transmit sound differently, some of the sound energy is reflected back toward the sound source, The returning sound waves are detected, and the distance from the sensor is deduced using the elapsed time from transmission to reception. An image is then created and displayed on a monitor. Ultrasonography issaft for preg nant and nonpregnant patiens ‘Most ultrasonography produces two-dimensional images. Threc~dimensional studies can be used for vol- ‘ume calculation and to provide detail about the surfaces of| particular structures. In gynecology, three-dimensional ultrasonography is especially useful in the evaluation of riillerian abnormalities (sce Chapter 4, Embryology and Anatomy.) Four-dimensional ultrasonography, which shows ‘movement, is also availabe. “Two kinds of probes are used in ultrasonography: trans- abdominal and transvaginal (Fig. 32.1). A transabdominal probe has an increased depth of penetration, which allows for the assessment of large uterine or adnexal masses. However, in obese patients, it may not allow proper imag- ing of pelvic structures. A transvaginal probe can be placed internally; thus, it often gives improved views of the cervix, uterus, ovaries, and tubes. Alo, ithasa higher frequency and shorter depth of penetration, which result in enhanced image clarity. ‘One of the most valuable uses for ultrasonography in gyne- ‘olgy i for imaging mases. The imaging technique helps dis- tinguish berween cystic and solid adnexal masses. Although ‘magnetic resonance imaging (MRI) or computed tomogra- phy (CT) can also be used for evaluation of ovarian cysts, ultrasonography is far less costly; for this purpose, experts consider it superior to either MRI or CTT. Itis also possible to delineate leiomyoma (fibroid) size and number using ultrasonography. ‘Use of the endometrial stripe thickness for evaluation of postmenopausal bleeding has been studied extensively Following menopause, the endometrium becomes atrophic and its thickness decreases, remaining relatively constant without hormonal stimulation. Ultrasonographic evalua- tion of the endometrial stripe involves measuring the thick- est portion of the endometrial echo in the sagittal plane. An endometrial stripe thickness of 5 mm or greater should be interpreted as abnormal in postmenopausal women not tak- ing hormone therapy. These patients should receive histo- logic assessment of an enclometrial tissue sample to exclude endometrial carcinoma. Saline infusion during ultrasonography (sonohys- terography, or SHG) can aid in the visualization of the endometrial cavity and can often identify intrauterine polyps or submucosal Ieiomyomas (Fig. 32.2). In this technique, saline is infused via a transcervicaly inserted catheter. ‘The saline acts as a contrast agent to delineate the endometrium, and intracavity masses. 'he primary role of SHG is inthe diagnosis of the cause of abnormal uterine bleeding (AUB). It is preferred over unenhanced ultrasonography in the 295296 Obstetrics and Gynecology “a C) FIGURE 32.1. Transabdominal (A) and transvaginal (8) ultrasonography. evaluation of AUB because ofits increased diagnostic accu racy and greater cost-eflectiveness. ‘Computed Axial Tomography Computed axial tomography (CT or CAT) scanning uses computer algorithms to construct cross-sectional images based on x-ray information. With the use of oral or intravenous contrast agents, CT scanning can help evaluate pelvic masses, identify lymphadenopathy, or plan radiation therapy. CT involves slightly greater radiation exposure than a conventional single-exposure radiograph, but provides significantly more information. The radiation dose of an FIGURE 32.2. Sonohysterogram showing several polyps. (From Broitkopf DM. Gynecologic imaging. In: Precis: Gynecology. 3rd ed. Washington, DC: American College ‘of Obstetricians and Gynecologists; 2006:17,) abdominal CT is stll below that thought to cause fetal harm, Nevertheless, because of CT's increased risk of fetal effects, magnetic resonance imaging (see below) or ultra sonography should be used for imaging instead of C whenever possible in pregnancy. Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is based on the magnetic characteristics of various atomsand molecules in the body. Because ofthe variations in chemical composition of body tissues (especially the content of hydrogen, sodium, Aoride, or phosphorus), MRI can distinguish between types of tissues, such as blood and fat. This distinetion is useful in visualizing lymph nodes, which are usually sur- rounded by fat; in characterizing adnexal masses; and in locating hemorrhage within organs. MRI is also useful for visualizing the endometrium, myometrium, and cystic structures in the ovaries. Emerging areas of clinical applic- ability include assessment of lesions in the breast and stag- ing of cervical cancer. Breast Imaging Mammography is an x-ray procedure used to screen for breast cancer. Itis performed by passing a small amount of, radiation through compressed breast tissue (Pig. 32.3) Because mammography has a high false-positive rate (10% per screening in postmenopausal women and as high as 20% per screening in obese or premenopausal women), additional testing may be required. Digital mammography allows better visualization of dense breast tissue than con- ventional mammography Ultrasonography is also used to evaluate cystic or solid breast masses and guide aspiration of eysts. MRT may also be used as an imaging technique for breast tissue.32 Gynecologic Procedures 297 FIGURE 32.3. Mammogram. (From Stedman's Medical Dic- tionary. 27th ed, Baktimore, MD: Lippincott Willams & Wilkins; 2000.) Hysterosalpingography Hysterosalpingography (FSG) is most often used to ‘evaluate the patency of the fallopian tubes in women who ‘may be infertile. After a radio-opaque dye is injected trans- cervically, fluoroscopy (live x-ray) is used to determine whether dye spills into the peritoneal cavity (Fig. 32.4). HSG can also be used to define the size and shape of the uterine cavity and to detect developmental abnormalities, such as a unicornuate, septate, oF didelphic uterus (see Chapter 4, Embryology and Anatomy). Italso can demon- strate most endometrial polyps, submucous myomata, or intrauterine adhesions that are significant enough to have important reproductive consequences. PROCEDURES Gynecologic procedures include diagnostic procedures such as biopsy and colposeopy, as well as procedures used as treatment modalities. Some procedures, such as laparoscopy and hysteroscopy, can be performed for both diagnosis and treatment and are chosen specifically for this reason, Genital Tract Biopsy Biopsies of the vulva, vagina, cervix, and endometrium are frequently necessary in gynecology. These proce- dures are usually comfortably performed in the office; they require cither no anesthesia or local anesthesia. ‘Vulvar biopsies are performed to evaluate visible lesions, persistent pruritus, burning, or pain. A circular, hollow metal instrument 3-$ mm in diameter, called a punch, isused to remove a small disk of tissue for evaluation ig. 32.5). For hemostasis, local pressure or anticoagulants (ctyptics) such as Monsel solution (ferric subsulfate) ot silver nitrate sticks are often used. Sutures are rarely nec essary. Local anesthesia is required for this type of biopsy. FIGURE 32.5. Biopsy of vulvar lesion. The punch is rotated place to incise tss298 _ Obstetrics and Gynecology FIGURE 32.6. Endometrial biopsy. (Figure adapted from the American College of Obstetricians and Gynecologists, © 2008.) Vaginal biopsy is performed to assess suspicious masses and to evaluate the vagina in the presence of cervical abnormalities. Women who have had a prior hysterectomy for cervical cancer should continue to have Pap tests per- formed on the vaginal cuff if result is abnormal, a vaginal biopsy may be required. Vaginal biopsy is performed with pinch biopsy forceps. Local anesthesia is rarely required. Cervical biopsy is performed with biopsy forceps and, pethaps, a colposcope (see below). No anesthesia is, necessary. Indications for cervical biopsy include chronic cervicitis, suspected neoplasm, or ulcer. Endometrial biopsy (EMB) is generally used to evaluate abnormal uterine bleeding, such as menorthagia, ‘metrorthagia, or menometrorrhagia, FMB is accomplished with a small-diameter catheter with a mild suction mecha- nism (Fig, 32.6). Various types are available. Anesthesia is, not necessary, but many patients are more tolerant of EMB when given ibuprofen (400-800 mg) 1 hour prior to the procedure. Colposcopy Colposcopy is performed to evaluate abnormal Pap results. Ic facilitates detailed evaluation of the surface of the cervi, vagina, and vulva when premalignancy or malignancy is suspected based on history, physical examination, or cytol- ogy. Cervical biopsy of suspicious lesions is frequently performed during colposcopy. Chapter 43, Cervical Neoplasia and Carcinoma, provides more detail about colposcopy. Cryotherapy Cryotherapy isa technique that destroys tissue by freez~ ing. A hollow metal probe (cryoprobe) is placed on the tis- sue to be treated. The probe is then filled with a refrig- erant gas (nitrous oxide or carbon dioxide) that causes it to cool to an extremely low temperature (between ~65 and -85 degrees C), freezing the tissue with which the cryoprobe is in contact. Cryotherapy is most often used to tweat cervical intraepithelial neoplasia and other benign, lesions such as condyloma. ‘The formation of ice crystals within the cells of the treated tissue leads to tissue destruction and subsequent sloughing. Patients who have had eryotherapy of the cervix can expect to have a watery discharge for several weeks as the tissues slough and healing occurs. Although cryotherapy is inexpensive, well-tolerated, and generally effective, it is less precise than other methods of tissue destruction, such as laser ablation or electrosurgery. Laser Vaporization Highly energetic coherent light beams (ight amplification by stimulated emission of radiation [LASER] may be directed onto tissues, facilitating tissue destruction or inci~ sion, depending on the specific wavelength of light used and the power density of the beam, Infrared (CO,) is the most common type of laser used in gynecologic pro- cedures. Yttrium-aluminum-gamnet (VAG), argon, or potassium-titanyl-phosphate (KTP) lasers, all of which have different effects on tissues, are also used. Some can, be used in the presence of saline or water. ‘The type of laser is selected according to the indication or desired effect of the surgery. Although expensive, the great pre- cision that laser offers makes ita useful tool in specific clinical settings. Laser therapy is used to treat vaginal and vulvar lesions, such as condyloma, vaginal intraepithelial neopla- VAIN), and vulvar intraepithelial neoplasia (VIN). Iso used to treat other dermatologic vulvar dis- orders, including molluscum contagiosur and lichen scle- rosis atrophia. Prior to the development of LEEP (see below), laser ablation and conization were common treat- ment modalities for cervical epithelial neoplasia ablation and cervical conization. Dilation and Curettage Dilation and curettage (D&C) is a procedure in which the cervix is dilated using a series of graduated dilators, followed by curettage (scraping) of the endemetriuom, for both diagnos- tic (bistalogic) and therapeutic reasons, D&C usually is per- formed under anesthesia in the operating room. Some common indications for D&C include abnormal uterine bleeding, incomplete or missed abortion, inability to per- form EMB in the office, postmenopausal bleeding, and sus- pected endometrial polyp(s). With the availability of newer imaging procedures, D&C is now less commonly performed,32 Gynecologic Procedures 299 Hysteroscopy [Hysteroscopy is the visualization of the endometrial cavity using a narrow telescope-like device (Fig. 32.7) attached toa light source, camera, and distension medium (often ‘normal saline) Itis used to view lesions such as polyps, intrauterine adhesions (synechiae), septa, and submu- ‘cous myomas. Special instraments allow directed resec~ tion of such abnormalities. Hysteroscopy is commonly performed in the outpatient setting under general anes- thesia; however, it can also be performed in the office asa diagnostic procedure or in conjunction with either ‘endometrial ablation or sonohysterography. A procedure for nonreversible sterilization has been, designed to be used in conjunction with the hysteroscope. In this procedure, metal coils are inserted into the ostium ofeach fallopian tube under direct visualization, Scarring of the tubal ostia then occurs. To confirm that the tubes are occluded, an HSG must be performed three months later. Endometrial Ablation Endometrial ablation is used to burn away the uterine lining. The procedure is used to treat abnormal uterine bleeding in women who do not wish to become pregnant. Itis not a method of sterilization; therefore, women who undergo ablation must use some other form of birth control. ‘Various ablation devices are available; some use heat, and others use cryotherapy. Some, but not all, of the available techniques involve direct visualization of the endometrium with a hysteroscope. Many women opt for endometrial abla- tion because itis a minor procedure, thus avoiding major surgery in the form of a hysterectomy. The procedure can be performed in either the surgical suite or office. In the office, a combination of nonsteroidal anti-inflammatory drugs, a local anesthetic, and an anxiolytic is used to pro- vide pain relief, FIGURE 32,7. Hysteroscopy. (Figure adapted from the American College of Obstetricians and Gynecologists, © 2006.) Pregnancy Termination Pregnancy termination refers to the planned interruption, of pregnancy before viability and is often referred to as, induced abortion, It is generally accomplished surgically through dilation of the cervix and evacuation of the uterine contents, accomplished under local anesthesia. Inthe first and carly second trimester, removal of the products of con- ception uses either a suction or a sharp curette, Suction curettes are often preferred, because they arc less likely to cause uterine damage such as endometrial scarring or per- foration, In the second trimester, destructive grasping for- ceps may be used to remove the pregnancy through a dilated cervix dilation and evacuation [D&E)). Alternatively in the first trimester (within 9 weeks of the first day of the last menstrual period), pregnaney can be terminated using medical rather than surgical tech- niques. Medical abortion may be carried out using one of the following methods © Mifepristone and misoprostol pills © Mifepristone pills and vaginal misoprostol * Mothotreate and vaginal misoprostol * Vaginal misoprostol alone ‘A woman who is still pregnant after an attempted medical abortion needs to have a surgical abortion, Cervical Conization Conization isa surgical procedure in which a cone-shaped sample of tissue, encompassing the entire cervical transfor- mation zone and extending up the endocervical canal, is removed from the cervix (Fig. 32.8). It may be required as the definitive diagnostic procedure in the evaluation of an abnormal Pap test when the colposcopic examination is inadequate, or when colposcopic biopsy findings are incon- sistent with Pap test results. Colposcopy-guided conization| ay also be used therapeutically in cases of cervical intra- epithelial neoplasia (CIN). Various techniques for coniza- tion are available, including cold knife (scalpel), laser excision, or electrosurgery (loop electrosurgical excision procedure (LEEP], also called large loop excision of the transformation zone [LLETZ)) Laser excision and LEEP are often performed in the office. Long-term complications ay include cervical insufficiency and stenosis. Laparoscopy Laparoscopy is the visualization of the pelvis and abdomi- nal cavity using an endoscopic telescope, which is most often placed via an incision in the periumbilical region (Fig. 32.9). The procedure may be diagnostic or thera- peutic. Laparoscopic evaluation and treatment may be performed for conditions such as chronic pelvic pain, endometriosis, infertility, pelvic masses, ectopic pregnan- cies, and congenital abnormalities. Sterilization (bilateral300 _ Obstetrics and Gynecology @) FIGURE 32.8. Conization of the cervix. (A) Cold knife technique. (B) LLETZ/LEEP (large loop excision ‘of the transformation zone/loop electrosurgical excision procedure) technique. FIGURE 32.9. Laparoscopy. (Figure adapted from the American College of Obstetricians and Gynecologists, © 2008.)32 Gynecologic Procedures 301 tubal ligation) using techniques such as bipolar cautery, clips, or bands can be accomplished easily via laparoscopy (see Chapter 25, Sterilization). During the procedure, car bon dioxide is insufilated to distend the peritoneal cavity to provide visualization, Additional instruments with diame: ters of 5-15 mm may be inserted via other laparoscopic incisions. ‘The number, length, and location of incisions depend on the instruments needed and the size of any tis sue specimens that are to be removed. Transvaginal inser tion of a uterine manipulator facilitates these maneuvers After laparoscopy, the most common complaints in- clude incisional pain and shoulder pain due to referred pain of diaphragmatic irritation from the gas used to provide visualization. Rare, but serious complications inckude dam- age to major blood vessels, the bowel, and other intra abdominal or retroperitoneal structures. However, when ‘compared with laparotomy, laparoscopy has several advan- tages, including avoidance of long hospital stays, smaller incisions, quicker recovery, and decreased pain. Hysterectomy ‘Hysterectomy, removal of the uterus, i still one of the most ‘commonly performed surgical procedures. In the United States, more than 500,000 hysterectomics are completed ‘annually. ‘The indications for hysterectomy are numer- ‘ous; they include abnormal uterine bleeding that has not responded to conservative management, pelvic pain, post- partum hemorrhage, symptomatic leiomyomas, symptom- atic uterine prolapse, cervical or uterine cancer, and severe anemia from uterine hemorrhage. Patients are often confused by inaccurate terms used to describe types of hysterectomy. To many patients, a “complete” hysterectomy means removal of the uterus, fallopian tubes, and ovaries, and a “partial” hysterectomy ‘means removal ofthe uterus but not the tubes and ovaries. ‘However, the correct term for the removal of both tubes and both ovaries isa bilateral salpingo-oophorectomy, and this procedure is generally not part of a hysterectomy. ‘Thus, itis important to determine exactly what procedure «patient may have had, Equally important is whata patient is expecting when a surgical procedure is planned. A total hysterectomy is the removal of the entire uterus, whereas a supracervical (or subtotal) hysterectomy removes the uter~ ine corpus while leaving the cervix. The uterus may be removed by several different routes. ABDOMINAL HYSTERECTOMY Abdominal hysterectomy is performed via a laparotomy incision. The laparotomy incision can be either trans- verse, usually Pfannenstiel, or vertical. The decision to perform a laparotomy involves many factors—the skill of the surgeon, the size of the uterus, concern for extensive pathology (e-g., endometriosis or cancer), the need to per~ form adjunct surgery during the surgery (e.g. lymph node dissection, appendectomy, omentectomy), and previous intra-abdominal scarring or surgeries. ‘VAGINAL HYSTERECTOMY ‘Vaginal hysterectomy is preferred if there is adequate uter ine mobility (descent of the cervix and uterus toward the introitus), the bony pelvis is of an appropriate configura tion, the uterus is not too large, and there is no suspected adnexal pathology. In general, vaginal hysterectomy is performed for benign disease. The advantage of vaginal surgery is less pain than with abdominal surgery, quicker return of normal bowel function, and a shorter hospital stay. If indicated, a unilateral or bilateral salpingo- oophorectomy can be performed in conjunction with a vaginal hysterectomy. LAPAROSCOPIC-ASSISTED VAGINAL HYSTERECTOMY Laparoscopic-assisted vaginal hysterectomy (LAVED, with or withouta bilateral salpingo-oophorectomy, is often performed for patients who desire minimally invasive surgery and may not have adequate descensus oftheir uterus to undergo a vaginal hysterectomy. LAVH can be accom= plished by performing most or all of the procedure lapa- roscopically; then the uterus is removed through the vagina. The vaginal cuffcan then be sutured transvaginally or laparoscopically ‘Torat Laparoscopic HYSTERECTOMY Many skilled laparoscopic surgeons are now performing a hysterectomy totally via the laparoscopic approach, This is usually accomplished with the assistance of a morcellator, which divides the uterus into multiple smaller specimens that can be removed through the ports. Even large uteri ccan be safely removed through small incisions, UROGYNECOLOGY PROCEDURES “Many gynecologists perform urogynecology procedures in the office and operating room. These procedures in- clude the Q-tip test, urodynamic tests, cystoscopy, trans- vaginal rape (sling), and the Burch procedure. A description of these procedures can be found in Chapter 28. PREOPERATIVE, INTRAOPERATIVE, AND POSTOPERATIVE CONSIDERATIONS Any surgical procedure carries risks. Naturally, more inva- sive procedures carry higher risks. Before patients sign preoperative surgical consent forms, they should be coun- seled on the risks of infection, hemorrhage, damage to302 _ Obstetrics and Gynecology surrounding structures (bowel, bladder, blood vessels, and other anatomic structures). Many hospitals require that patients also sign a consent form fora blood transfusion in case of an emergency. Some patients refuse to sign such consents for blood transfusion for personal or religious reasons, and this should be clearly documented in the chart. A discussion with the patient regarding the safety of the blood used for transfusion should address the risk of acquiring human immunodeficiency virus (HIV), hepati tis B and C viruses, and other blood-borne pathogens. Preoperative testing, which could include blood work, urinalysis, other laboratory tests (glucose, creatinine, hemoglobin, coagulation parameters), pregnancy testing, lectrocardiogram, and imaging studies (e.g., CT, MRD) should be individualized based on the patient’ age (espe cially in pediatric patients), concurrent medical problems, route of anesthesia, and surgical procedure planned. ‘Minor procedures are now more commonly performed in the office setting for patient convenience, avoidance of general anesthesia, and impraved reimbursement. In addition, not all, patients are surgical candidates, and nonsurgical therapeu tic options should always be considered. Patients may have such significant medical problems (e.g., poorly controlled diabetes, heart disease, pulmonary disease) that they might not tolerate anesthesia or surgery. Several intraoperative and perioperative issues should be considered. Prophylactic antibiotics are indicated for some gynecologic surgeries and should be administered within 30 minutes of surgery. Often, a Foley catheter is, inserted prior to surgery to prevent the bladder from becoming distended during the procedure. A preoperative pelvic examination of the anesthetized patient can some: times prove useful. Postoperatively, a nurse and a member of the anesthe sia team assess the patient in the postanesthesia care unit. “The patients cither discharged to home or admitted to the hospital, depending on the type of procedure performed and the condition of the patient. An operative note will have been written in the chart immediately postoperatively, out- lining the preoperative diagnosis, postoperative diagnosis, procedure, surgeon(s), type of anesthesia, amount and type of intravenous fluid administered, any other fluids given (eansfusions or other products), urine output (indicated), findings, pathology specimens sent, complications, and a statement of patient’s condition upon completion of the procedure. Postoperative orders for inpatient stays should include a notation of the procedure performed, the name of the attending physician and service, frequency of vital signs, parameters for calling the physician, diet, activity, intra venous fluids, pain medications, resumption of any home ‘medications (antihypertensives, diabetic drugs, antidepres sants, ec), antiemetic medications, deep venous thrombo- sis (DVD) prophylaxis, Foley catheter, incentive spirometer, and any necessary laboratory studies. During 2 postoperative hospitalization, the patient should be seen at least daily. Careful assessment and moni- toring of pain, bladder and bowel function, nausea and. vomiting, and vital signs are routine. Early ambulation can reduce the risk of thromboembolism. The most common surgical complications are fever, urinary tract infections, surgical site drainage and bleeding, minor separation of skin incisions, hemorshage, pneumonia, ileus, and minor surgi- cal site infection(s). Less common postoperative complica: tions include skin and subcutaneous wound separation, fascial dehiscence or evisceration, bowel perforation, uri- nary tact injury, severe hemorthage requiring reoperation, DVT, pulmonary embolism (PE), abscess, sepsis, fistulas, and anesthetic reactions Fever is defined as two oral temperatures of greater than or equal to 38°Cat 4-hour intervals. Primary sources| of fever include the respiratory and urinary tract, the inci sion(s), thrombophlebitis, and any medications or transfu- sions. Atelectasis occurs when patients do not take large inspiratory breaths due to abdominal discomfort. Use of an incentive spirometer can minimize the risk of atelectasis and pneumonia. Use of an indwelling urinary catheter should be minimized, because placement for more than 24 hhours increases the risk of urinary tract infection (cystitis, or pyelonephritis). Ambulatory status affects breathing (hypoventilation) and possible thrombosis (DVT or PE). ‘The wound should be assessed for any signs of infection. If there areno easily visible incisions as with vaginal surgery, a pelvie examination and/or imaging of the pelvis may be needed. I'the fever resolves after withdrawal ofa medica tion, then a presumptive diagnosis of drug reaction ean be made. Ifthe patient has received blood products, the pos- sibility of a reaction to antigens in the transfusion should be investigated as a cause of the fever. Antibiotics should be ordered only when infection is suspected. SUGGESTED READINGS American College of Obstecrcians and Gynecologists, Antibiotic prophylass for gynecologic procedures. ACOG Practice Bulletin No. 74, Obstet mec, 2006:108(1)225-284 American College of Obstetricians and Gynecologists. Diagnosis ‘snd. management of vulvar skin disorders, ACOG Practice Bulletin No. 93. Oster Gynec 2008111( 1243-1253. American College of Obstetricians and Gynecologists. Endometrial ablation, ACOG Practice Bulletin No. 81. Obstet Gynec. 2007; 109( 1283-1248. American College of Obstetricians and Gynecologists, Management ‘of abnormal cervical cytology and histology. ACOG Practice Bulletin No. 66. Obstet Cyc 2005;106( 685-664 American College of Obstetricians and Gynecologists, Patient safety in obstetrics and gynecology. ACOG Committee Opinion No. 286 (Obstet ec 2003102 583-85. Breithopf DM. Gynecologic imaging. In: American College of, ‘Obstetricians and Gynecologists. Precis, An Update rm Obsetrs and Gyneclogy: Gyneseligy: 3rd el. American College of Obstetricians and Gynecologists, 2006:15-25,