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
