Mais les résultats doivent être attendus longtemps et il n'y a généralement pas de temps azithromycine prix L'autre cas, c'est que l'achat d'un ou d'un autre antibiotique dans une pharmacie classique nécessite des dépenses matérielles considérables et pas toutes les personnes ne peuvent acheter des produits pharmaceutiques aussi coûteux.
Microsoft word - ablation 76-100.doc
•
Stenosis
•
Dilated canal
•
Lacerations
•
Fragile
Cervical Stenosis
False Passage & Perforation
•
Frequency: 1.3-3.0 %
•
Reasons:
•
Solution:
Perform diagnostic hysteroscopy to chart the endocervical canal
Open Speculum
Cervical Dilators
Stenosis of the Cervix
•
Operative Hysteroscopy
22 – 26 F (7-9 mm)
•
Global Ablations
15-24 F (5-8 mm)
Cervix Dilatation
Diameter
Novasure
Her Option
ThermaChoice
Inability to Dilate the Cervix -
Stenosis
•
Laminaria
•
Misoprostol (Cytotec)
•
Vasopressin
Inability to Dilate the Cervix –
Cytotec (Misoprostol)
•
200-400 mcg
•
Oral or vaginal
•
3-24 hours prior to procedure
•
Tmax: 12mins
•
Time reduced: 40 vs 120 sec
Cytotec (Misoprostol)
Side Effects
•
Nausea
•
Diarrhea
•
Uterine cramps
•
Bleeding
Inability to Dilate the Cervix -
Vasopressin
•
Vasopressin 20 mL
(4U of 0.05 U/ml in 80mL of NS)
•
Intracervically 4 & 8 o’clock positions
• Decreased force from 37 to 20 lbs
• Complications: MI, cardiac arrest
Excessive Cervical Patency
•
Complication:
-Loss of a seal
•
Solutions:
-2 tenaculums
-Gimpelson tenaculum
-EndoLoop
-Use ThemaChoice, Her Option, Microsulis
Office Setting Recommended
Anesthesia and Pain Management1
•
Pre - Procedure
–
NSAID:
Toradol 10 mg, (Ibuprofen 800mg
(Ponstel 250mg, Cataflam® 50mg, Celebrex® )
–
Anxiolytic: Ativan 1 mg, (Diazepam 10mg)
–
Opiate analgesic: Lortab 10/500, (Vicodin
® 2
***All are taken at home 1 -2 hours pre procedure. NSAIDs are also
taken the night before
–
Toradol® 30 mg IM (peripheral PG blocker) +
Atropine 0.4mg IM (prevents vaso-vagal) 30 min
pre procedure
1Author’s experience and recommendation
Local Anesthesia
Potocky® Needle
Local Anesthesia
•
Toxic Dose Lidocaine
¾1%
Lidocaine Without Epi =
300mg (
30cc)
Uterine Pathology
•
Endometrial hyperplasia
•
Atypical endometrial hyperplasia
•
Adenomyosis
•
Polyps
•
Fibroids
Anticoagulated Patients
•
Need to stop anticoagulation?
•
Need to alter procedure?
•
Is there a best method?
Contraindications:
Prior Surgical
•
Classical C-section
•
Myomectomy
•
Metroplasty
Repeat Ablations
•
Was failure delayed or immediate?
•
If immediate, what is the reason for
failure:
¾
Technical problems
¾
Uterine deformity
¾
Adenomyosis
¾
New pathology: carcinoma, fibroids,
Adenomyosis
Repeat Ablations
•
Pre operatively, repeat studies
including biopsy and labs
•
What method should be used for repeat
ablation?
Depends on the reason for failure
Source: http://www.neogs.org/Syllabus/Ablation%2076-100.pdf
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