Atlas of Colposcopy: Principles and Practice

Primary haemorrhage: Excessive bleeding may occur during LLETZ if the cervix is congested and hypertrophied, the transformation zone is large, and the lesion extends too far laterally. Moving the loop through the cervix too quickly or interrupting the excision midway also induces more bleeding. Rarely, the loop may injure the lateral vaginal wall, resulting in profuse bleeding. To prevent excessive bleeding during the procedure, adrenaline should be added to the local anaesthetic, a higher coagulation current should be used for a large, congested cervix, and the procedure should be completed in a single smooth, slow, deliberate motion of the loop through the cervix. If the loop stops cutting midway, withdraw the loop to see whether it is intact. If the loop is intact, increase the cutting current by 5 W and try again through the original incision. Gradually increase the cutting current until the loop starts working.
If there is excessive bleeding after the transformation zone is excised, take a piece of dry gauze on a sponge-holding forceps and press the wound. Get an assistant to help you. Remove the piece of gauze and try to identify the source of heavy bleeding under colposcopy. Usually it is a spurting artery. Use the gauze on the forceps to dry the area with one hand and the diathermy with the ball electrode with the other hand and try to cauterize the vessel. Increase the coagulation current to 50 or 60 W. Once the major bleeding is controlled, systematically cauterize the entire wound, starting from the periphery of the anterior lip. After haemostasis is secured, loosen the blades of the speculum and check whether new bleeding points appear because of the release of pressure.
If no obvious source of bleeding is seen on the cervix, check the lateral vaginal walls for tears. A tear on the lateral vaginal wall needs to be stitched with a polyglactin suture. Remove the self-retaining speculum and introduce the anterior and posterior vaginal retractors. Expose the injury and infiltrate with a local anaesthetic agent. Apply interrupted or continuous stitches to stop the bleeding. Rarely, stitches are required to stop bleeding from the cervix.

Secondary haemorrhage: The woman may return after a few days complaining of heavy bleeding with passage of clots. The woman should be assessed and resuscitated appropriately. The vagina should be cleared of all clots, and a tight vaginal pack should be applied. Antibiotics should be started or changed. Removal of the pack after 24 hours usually stops the bleeding in most cases. If bleeding persists, the woman should be moved to the operating theatre for exploration, preferably under general anaesthesia. Bleeding points should be secured by deep stiches with a polyglactin suture and with diathermy.

Vaginal discharge: Most patients have minimal vaginal discharge for 2–3 weeks after the procedure. After a week, the discharge usually becomes heavier and may be bloodstained. This may persist for about 2 more weeks. Patients should be counselled before hand.

Pelvic inflammatory disease: Rarely, the woman may have pelvic inflammatory disease, characterized by lower abdominal pain and foul-smelling vaginal discharge with or without fever.

Cervical stenosis: Stenosis of the external os is seen in 2–3% of cases during follow-up.

Premature rupture of membranes and preterm labour: Excision of large transformation zones or type 3 excision is associated with a higher risk of premature rupture of membranes and preterm labour in subsequent pregnancies.