Case List- Gyn Flashcards
Ectopics
-incidence
-risk factors
-heterotopic incidence
-with IVF
-2%
-prior ectopic, prior tubal surgery, adhesive disease (endometriosis), PID, ruptured viscous
-1/30K
-1/100
What antibiotics do you use for PID?
Ceftrixone, Doxycycline, Flagyl
CPP
- definition
-differential diagnosis
Pain perceived to originate from pelvic organs > 6 months
Ddx: cervicitis, chronic PID, adenomyosis, hydrsalpinx, ovarian cysts/tumors, endometriosis, adhesion, urological- PBS, urethral diverticulum, IBS, diverticulosis, celiac disease, deprressoin/anxiety, PTSD, myofascial
Chorionic villi on histology
small like finger projections
MTX ABSOLUTE CIN
-IUP/heterotopic
-breastfeeding
-leukopenia/thrombocytopenia
-RUPTURED ECTOPIC
-HD unstable
-inability to follow up
-severe hepatic.renal disease
-active PUD
-active pulmonary disease
MTX relative CIN
-refusal to accept blood
-GS > 4 cm
-HCG high initially (5000) - higher failure rate
-Live ectopic
5 Case
-risks of ectopic general population
-risks of ectopic with IUD LNG
-risks of perforationion
-high risk for ectopic with IUD LNG or Cu?
1) 2%
2) <1% (0.09)
3) 1/1000
4) higher risk of an ectopic with Copper IUD
How do you dose MTX?
-say SINGLE DOSGING IM
HCG DAY 1 AND DAY 4 AND 7
Decline of 15% between 4-7
If no decline and patient continues to be stable, consider repeat MTX vs. surgical therapy.
-if declining, follow HCG weekly until negative
-If receive two doses and inadequate response, proceed to surgery!
What is the baseline risk for miscarriage?
What percent occur during 1T?
How does anesthesia affect miscarriage risk?
Baseline risk of fetal anomaly?
10%
80% in first trimester
Some studies show slight increase of miscarriage in first half of pregnancy, uncertain if this is due to anesthesia, bodies response to surgery or illness
5%
Medical management of SAB with
-expectant
-Cytotec
-Mifepristone + cytotect
-80% (up to 8 weeks)
- 80% (single dose is 70%)
-significantly increased success and decreased need to surgical therapy
TXA MOA
Dose: 1.3 mg TID PO or 1 gram IV in 100 ml over 10 minutes
prevents plasmin formation, thus stabilizing the fibrin matrix
- What are CIN to anti-fibrinolytic therapy.
Allergy, VTE history, intracranial bleeding, known defective color blindness
What are the chances of each type of hyperplasia progressing to cancer for each type?
o Simple without atypia 1%
o Complex without atypia 3%
o Simple with atypia 9%
o Complex with atypia (EIN) 40%
What is DDX of Post menopausal bleeding?
Endometrial atrophy, polyp, leiomyoma, hyperplasia, EIN, atrophic vaginitis, urological conditions/stones
When do you hault a Hscope?
In a healthy individual, I assess around 1000 however haulting the procedure is necessary at 2500
-Fluid deficit would be 750 to 1000
Risks of endometrial polyp malignancy
- Premenopausal 2%
- Post menopausal 5%
What about CERVICAL POLYPS, risk of malignancy?
close to 2% malignant
higher risk if post menopausal
Do you do routine cystoscopy?
No. I find the ureteral course at the start of my hysterectomies and follow the ureter into the pelvis. When I am coagulating and transecting the uterine vascular pedicle, I stay medial. I do a cystoscopy if there is extensive dissection along the pelvic side wall outside of the norm.
I also work in a group where we do a high volume of laparoscopic hysterectomies. With a laparoscopic hysterectomy the highest likelihood of an injury is through thermal injury at the time of coagulating the cardinal ligaments, a cystoscopy will not detect a delayed thermal injury.
How do you determine route of hyst?
Though I know a vaginal hysterectomy is the preferred route of hysterectomy, I first and foremost determine if the patient is a good candidate for a VH.
-gravidity
-surgeries
-risks for adhesions
-vaginal caliber
-descensus
- uterine size/symmetry
If there is limited descensus or an extensive surgical history to include multiple abdominal surgeries with risks of adhesive disease, then I consider the next minimally invasive option, a laparoscopic hysterectomy. The decision between robotic vs. laparoscopic is made based on the uterine size, body habitus, patient comorbidities, OR availability, and through shared decision making, as well as the potential for extensive adhesive disease.
In my current clinical practice, I am a referral basis for the robot. I consider the above criteria and if the patient is a candidate for a minimally invasive approach, I discuss these approaches. I am most comfortable with robotic hysterectomies and have well trained support staff.
If the patient is not a candidate due to uterine size or concerns for significant anterior abdominal wall adhesions, then we talk about TAH vs. referral to a gyn onc.
l also assist my partners with their TLH’s and VH. In the next 5 years, I would like to become more proficient with VH, and I am in the process of doing so with my senior partners as my mentors. I would like to incorporate more VH’s into my practice if there is a good candiate.
Hysterctomy and ovary removal
speal
-risks of subsequent ovarian surgery if ovaries left inset?
Risks ovarian cancer?
-age
-5% risk of resurgery
1/70 risk ovarian cancer
What is the most common diagnosis of CCP?
What should you do in work up to make sure you aren’t missing anything?
1) endometriosis
2) adhesions
3)IBS
4) PBS/IC
Screen for Anxiety/Dep
What is vulvodynia?
chronic vulvar pain (>3 mo) without an identifiable cause (diagnosis of exclusion)
What is vestibulodynia AKA …
localized vulvodynia
How do you evaluate vulvodynia?
History
Skin complaints
PMH: relevante info- IBS, fibromyalgia, trauma, infection
Hygenic practices
Any allergies
Previous treatments tried
PE: skin eval
neuro eval (anal wink and bulbcavernosus reflex)
Q tip test to locate pain
Rule out vaginitis
Consider biopsy if refractory
MSK: rule out pelvic muscle overactivity/hypertonicity
what is the anal wink testing and how do you perform?
what is the bulbocarvenosus reflex?
1) skin near perineum, intact pudendal nerve = contraction of external sphincter
2) tap clitoris and external sphinter reflex (checking S2-S4)
What is the success rate of Methotrexate for ectopic pregnancy?
Around 90%
Case #8:
Was this patient evaluated for a coagulopathy?
2)what types of fibroids are there, and what types bleed?
1) No, this patient had acute on chronic blood loss anemia.
- Due to heavy menstural blood loss, she did not have enough iron to make enough hemoglobin (in the bone marrow)
2) submucosal and intramural are more likely to bleed.
-Submucosal as they are abutting the endometrium and increasing endometrial surface
Intramural: due to the neovarscularization around the fibroid to the pseudo capsule (with friable vessels) as well as the
-larger size prevents the uterus from contracting down and controlling bleeding and/or more likely to ulcerate/degenerate and cause increase in bleeding
Cellulitis:
-risk factors
-most common bacteria?
-ddx of wound area that is red?
-treatment for MRSA
Risk factors: Diabetes, venous insufficiency, PAD, lymphadema, hx MRSA
-Staph Aureus, Streptococcus, Enterococcus
-hematoma, seroma, abscesss, retained suture
Bactrim BID x 7-10 days or
Clinda or Doxy
Wound packing principles-
Do you want wet or dry packing?
Want wound packing material to be moist and warm to facilitate healing
Moisture bc wound fluids contain tissue growth factors that facilitate re-epithelizlization
When you remove the dressing, you want it to be moist still and the necrotic tissue will be removed with is, so its a way of debriding the area
What is the incidence of surgical site infection after hysterectomy?
2%
How to explain granulation tissue
Granulation tissue is a key component of the wound healing process- proliferation phase.
It consists of new connective tissue and tiny blood vessels that develop in the wound bed as part of the body’s response to injury.
This tissue appears pink or red in color and has a granular or bumpy texture, hence the name “granulation.”
Essentially, granulation tissue serves as a scaffold for the formation of new tissue and blood vessels, helping to fill in the wound and promote healing
What is hyper granulation tissue and why do we care??
- impede the healing process by delaying wound closure and increasing the risk of infection.
What does silver nitrate do?
-Bacteriocidal - prevents new growth
-Reduce inflammation
-promote tissue regeneration.
Minimize the risk of complications, such as wound infection or delayed healing.
What are the evidence based advantages of a Robotic Hysterectomy?
**
15: Alternative management bedsides hysterectomy for CIN 2-3..
CIN 3 with + Margins (only)- ->
Repeat excision showed CIN 2 positive margin–>
- could have done a CKC
- CIN 2 positive margin…. conservative mgmt would be to Colpo with ECC at 4-6 months
How long does it take for the vaignal cuff to fully heal?
How long does it take for O-Vicryl sutures to dissolve?
How long does it hold its tensile strength?
8-12 weeks
dissolves fully at 8-10 weeks (by hydrolysis)
tensile strength held up for 3 weeks
Hysterectomies #16 and 27–> why did you not do a cystoscopy?
-I identified the course of the ureter and peristalsis was noted bilaterally after cuff closure.
-There was adequate exposure, manipulator placed cephalic to displace the ureters, and the greatest risk of injury for this patient would be while dividing the cardinal ligament, and a cystoscopy would not pick up a thermal injury.
CAse # 21
Why did you aspirate instead of
o Upon entry in the abdomen, there was a small amount of free fluid in the pelvis, this was suctioned. The residual cyst was small, thus the decision was made to aspirate the cyst rather than perform a cystectomy due to risks of compromising the ovarian parenchyma/bleeding.
patient also was considering future children, thus I did not want to compromise the fallopian tube potency
Adnexal mass guidelines:
1)Simple vs. Complex…
2) What characteristics should you proceed to surgery…
1) Simple ovarian cysts up to 10 cm are likely benign and can be observed via serial US (even in post menopausal women)
2)
Complex, internal architecture
solid mass
BL massess
suspicious findings on US
elevated tumor markers
ascites
symptomatic mass OR torsion
How do you diagnose PID?
Lower abdominal pelvic pain in sexually active female and other causes have been ruled out. + symptoms of adnexal or uterine tenderness and/or CMT + supporting evidence
How do you work up a post menopausal patient with an ovarian mass?
1) H&P
2) US
3) Tumor markers
IF suspicious.. work up further with
4) CT scan ( and consider lung CT to look for pleural effusions)
Surgical approach: midline vertical is standard approach (less data for ovarian cancer with robot than for cervical/uterine)
Washings
Frozen sectoin
Definitive therapy: Hysterectomy BSO, omentectomy, LAD, debunking
Differential diagnosis for ovarian masses:
Solid
-oma’s (except teratoma)
Fibroma, thecoma, dysgerminoma
fibroid- pedunculate
brenner, granulose cells
Differential diagnosis for ovarian masses:
cystic
functional, serous, mucinous, mature cystic teratoma, endometrioma
Types of ovarian cancer:
serous epithelial
non-epithelial ovarian
Which tumor markers are elevated?
1) Serous CA 125 (50% of the time for Stage 1 epithelial have NORMAL VALUES)
Non epithelial ovarian
-all the others
AFP
yolk sac or embryonal tumors
HCG
choriocarcinoma, embryonal carcinoma, dysgerminoma
granulose cell tumor
estrogen and inhibit
androgens
thecoma, fibroma, sertoli leydig
LDH
dysgerminoma
Case of the day- young female found to have dysgerminoma… What do you do?
What are some characteristics of dysgerminomas?
1) Unilateral SO (conserves CL ovary/uterus)
2) follow with serial tumor markers (LDH)
3) Chemosensitive with Bleomycin, Etoposide, Cysplatin
2/3 dx at early stage
any extremely large ovarian mass is most likely a…
benign mucinous cyst adenoma
Cystic adnexal mass in a post menopausal woman…
what is the risk of ovarian cancer?
«1%
If post menopausal patient has a 10 cm simple cystic mass with normal tumor markers, what would you do if asymptomatic?
what about if symptomatic?
Recommend surgical removal as being post menopausal and increased in size > 10 cm, I would recommend removal.
Though the majority (80%) of ovarian neoplasms in post menopausal patients are benign epithelial (cyst adenoma)
What tumors can metastasize to the ovary?
Breast
GI (colon, stomach, appendix)
Endometrium
Lung
Lymphoma
What are the criteria for a borderline tumor?
epithelial stratifications
papillations
nuclear atypia
NO STROMAL INVASION
How do topical steroids prevent wound healing?
interfere with normal healing process, prevent inflammation and fibroblast proliferation, and collagen synthesis and re-epithelialization
what is the most likely malignant type of ovarian tumor in a young female?
what tumor markers will be elevated?
(think about case 21)
germ cell tumor: AFP, HCG, LDH
Case # 23:
What did you expect gyn onc to do? Do they need to go back in and operate on this patient? Did your surgery stabilize pt?
o My main concern in the ER was to perform a diagnostic laparoscpy due to her acute abdomen to find a source of her pain, and her US report as inconclusive, stating venous flow to the ovary but inconclusive arterial flow. Given that venous flow will typically be present in a torsion before arterial flow loss, this was not adding up. Upon entry, it was evident that her pain was due to the extent of her endometriosis and ruptured cyst. After evacuating the cystic fluid, pictures were taken to document the extent of disease.
Based on her extensive adhesive disease and frozen pelvis, the decision was made to discontinue the procedure for several factors as continuing surgically would put this patient at increased risk of bleeding and/or needing a hysterectomy which would likely end up needing to be done as a laparotomy due to risks of bleeding, lack of exposure.
I felt that referreing her ot gyn onc post operatively for a minimally invasive approach was safer for the patient and less risks of surgical injury.
IUD perforation
Incidence
Risk factors?
1/1000
Perforation: experience level, PP insertion, breast feeding, extreme anteflexion/retroflexion
IUD expulsion rate?
<20, HMB, dysmenorrhea, PP, post abortion, large submucosal fibroid
Uterine Artery embolization
Benefits
disadvantages?
What is the re-intervention rate at 5 yrs?
1) reduced bulk symptoms, reduced menstrual flow, reduced size, avoidance of hysterectomy
2)reduction in ovarian function, complications
-15%
What is the incidence of leiomyoma?
What is a leiomyoma?
Race ?
70% of women by menopausa
25% symptomatic
Leading cause of hysterectomies
solid tumor comprised of smooth muscle cell and fibroblasts
AA have 2-3x more
What does the evidence say regarding NSAIDS and Fibroid treatment?
does help decrease menstrual loss however no evidence specifically for treatment of AUB-L
What are the complications of a UAE?
unplanned hysterectomy: uterine perforation, intraperiotneal injury, hemorrhage
rehospitalization: bacteremia from arteriotomy, myometritis, pulmonary embolus
post embolization syndrome - fevers, chills, nausea, myometrial infarction, pelvic infection, discharge, failed procedure
UAE: contraindications
pregnancy, desire for future children, active pelvic infection, post menopausal, contrast allergy, radiation history
Which procedure has the higher re-intervention rate at 3 years? Hyst, UAE, Myomectomy?
UAE has a higher reintervention rate
25 - did you offer her a myomectomy?
Just be familiar with this..
Yes, I did offer her a myomectomy as well as a UAE as she was done with child bearing. This patient wanted to most minimally invasive surgical approach with the quickest return to work.
With shared decision making, we decided that a radiofrequency ablation would be a better treatment for her due to smaller surgical incisions and less risk of requiring a hysterectomy. Due to the size of her fibroid, she would need a larger umbilical incision to remove the fibroid with a myomectomy. The fibroid was also located in the posterior uterus near the left uterine artery thus, there was an increased potential for vascular injury and requiring a hysterectomy should this be significant.
TAH - read your notes!
27: Why were you involved?
ER was concerned for sepsis due to tachycardia, HTN, and history of abortion 2 months ago…
No leukocytosis
HCG low
She had no signs of septic abortion- adnexal tenderness, no fundal tenderness, afebrile
SIRS criteria
HR >90
Temp > 38 (or <36)
RR >20
WBC > 12,000 or < 4,000
How does a septic abortion present?
Treatment?
pregnancy <20 weeks
history fo pregnancy, including termination
pelvic pain, uterine tenderness, vaginal bleeding, and/or discharge, and/or fever
Sepsis work up, cultures + blood cultures, Broad spectrum antibiotics (Pipercillin and Tazo= Zosyn), US guided suction D&C
What term is sued for infection > 20 weeks in uterus?
Chorio
What is the incidence of septic abortion?
what is the mortality rate from septic abortion?
rare…
mortality rate: depends on the gestational age at the time of abortion of miscarriage, but in first trimester about 2%
Ruptured ovarian cyst.. how to explain
Unfortunately, yes the cyst was ruptured when it was removed. Though every attempt was made to preserve the integrity of the cyst, the cyst wall was very thin and ruptured during the dissection.
What is Fitz Hugh Curtis Syndrome?
complication of PID
Pt presents with RUQ pain and definitive diagnosed of Laparoscopy
Can cause infertility
Why do we put patients on C-OCP to suppress cysts? How does it work?
Progesterone suppresses ovulation by preventing FSH release, thus less follicle development
the follicle are then not secreting estradiol, so you don’t get an LH surge
Post-op emesis management
-main cause?
pain…
This patient was transferred from the outpatient surgery center to the hospital for prolonged observation. AS her pain was controlled and vitals stable, I asked anesthesia to give the patient a scopolamine patch in addition to trying anti-emetics available at the surgery center (Zofran, companize, Phenergan). I assisted with the transfer and signed the patient out to my partner who was covering overnight. Advanced her diet slowly. The patient clinically improved with time and the above measures.
What are risk factors for tubal regret?
Nulligravidy, age < 30, decision made during traumatic event, single status, poor access to info about sterilization, short timbe between delivery and sterilization
US findings diagnostic of pregnancy failure
CRL > 7 mm no heart beat
MSD 25 mm and no fetal pole
GS+ YS present and repeat US in 11 days without heart beat
GS (no yolk sac) and repeat scan in 2 weeks and no heart beat
Talk about the expulsion rate of IUD intra-op vs. 2-6 weeks post op insertion after suction D&C?
Expulsion rate is similar … so offer it!
Early pregnancy loss and thrombophilias…
inherited thormbophilias commonly thought as a cause however only APLS has been shown to show significant association with EPL.
Use of anticoagulants, ASA or both has not bee shown to reduce EPL in women with thrombophilias except in APLS
Surgical treatment of Early Pregnancy Loss success rate?
nearing 99%
Medical management of SAB - heavy bleeding precautions
Soaking 2 pads per hour for 2 consecutive hours
37: Hemmorhagic shock patient
Patient was previously in the ER the day prior with complaints of bleeding and Hb was 13.7 at that time. Seen by a different provider planning expectant mgmt.. She was sent home and returned with heavy bleeding (EBL in ED approximately 1L), tachycardic, hypotensive and near syncopal.
What are the risk factors for a molar pregnancy?
Miscarriage (though molar can occur after a term pregnancy)
history of molar pregnancy
AMA, young age <20,
smoking
infertility history
What is the recurrence risk of a molar pregnancy after 1?
Recurrence after 2?
1) 2%
2) close to 20% (15-18%)
Post molar surveillance, when are you concerned for GTN?
Rising or plateauing HCG values
Rising: in two weeks, rise of > 10% over 3 values
Plateau: over 3 weeks, values within 10% of each other
When would you consider a hysterectomy for a molar pregnancy?
> 40 yo
high HCG > 100 K
bilateral theca lutein cysts > 6 cm
Partial mole contents…
Both maternal and paternal
(69 XXX or 69 XXY)
Complete mole contents
all paternal
XX or XY
Explain to a patient a partial mole and how it develops..
Partial molar pregnancy is a result of the union of an ovum and two sperms. Therefore, the genetic content of the fetus is imbalanced with overrepresentation of paternal genetic material. Since the maternal chromosomes are present, the embryo can develop to a certain point.
Explain how a complete mole develops
The complete mole is the result of a union between an empty ovum and generally two sperms.
No fetal tissue (empty egg)
41- vaginal cuff abscess
what antibiotics did you use?
broad spectrum, Zosyn
Vaginal cuff abscess management- see flow chart
