Chapter 40 - Gynecology++ Flashcards
1
Q
What does the round ligament do?
A
Allows for anteversion of the uterus
2
Q
What does the broad ligament contain?
A
Uterine vessels.
When these are ligated during hysterectomy, watch for ureters.
3
Q
What does the infundibular ligament contain?
A
Ovarian artery, nerve, vein
4
Q
What does the cardinal ligament do?
A
Base of broad ligament, holds cervix and vagina to pelvic wall
5
Q
When can you see pregnancy on ultrasound?
A
Six weeks
6
Q
With what beta hCG is a fetal pole seen?
A
6000
7
Q
At what hCG is a gestational sac seen?
A
1500
8
Q
What is a missed abortion?
A
First trimester bleeding, closed os positive second ultrasound, no heartbeat
9
Q
What is a threatened abortion?
A
First trimester bleeding, positive heartbeat
10
Q
What is a incomplete abortion
A
Tissue protrudes through os
11
Q
Ectopic pregnancy psx and dx?
A
Psx: Acute abdominal pain, missed period, vaginal bleeding, hypotension
Dx: positive beta hCG, negative ultrasound for sac
12
Q
What are risk factors for ectopic pregnancy?
A
Previous tubal manipulation, PID, previous ectopic pregnancy. Shock and hemorrhage can occur from the ectopic pregnancy.
13
Q
What are the symptoms of endometriosis and how is it diagnosed?
A
Dysmenorrhea, infertility, dyspareunia
Laparoscopy shows blue mass
14
Q
What are the symptoms of pelvic inflammatory disease?
A
Psx: Pain, nausea, vomiting, fever, vaginal discharge. Most commonly occurs in the first half of the menstrual cycle. 2/2 Disruption of the cervical mucus barrier.
Risk factors include promiscuity/sexual activity
Dx: Cervical motion tenderness, cervical cx, Gram stain.
15
Q
What is mittelschmerz?
A
Rupture of graafian follicle. Causes pain that can be confused with appendicitis. Occurs 14 days after first day of menses
16
Q
What is the number one type of vaginal cancer?
A
Squamous cell carcinoma. DES can cause clear cell carcinoma
17
Q
What is botryoides?
A
Rhabdomyosarcoma of the vagina that occurs in young girls
Xrt
18
Q
What are risk factors for vulvar cancer?
A
Old, obese, nulliparous; HPV
SCC
TX: less than 2 cm wide - local excision and ipsilateral inguinal node dissection.
Greater than 2 cm - vulvectomy with bilateral inguinal dissection, postop XRT
19
Q
What is the leading cause of gynecologic death?
A
Ovarian cancer.
Decreased risk with OCP’s and bilateral tubal ligation.
Increased risk with more ovulation episodes - nulliparity, late menopause, early menarche
20
Q
What are the types of ovarian cancer?
A
Teratoma, granulosa theca, Sertoli leydig storms ovarii, choriocarcinoma, mucinous, serous papillary
21
Q
What type of ovarian cancer has the worst prognosis?
A
Clear-cell
22
Q
What stage ovarian cancer is bilateral ovaries?
A
One
23
Q
What is the most common initial site of regional spread of ovarian cancer?
A
The other ovary
24
Q
What is the treatment for ovarian carcinoma?
A
Often presents late. Survival is improved by debulking.
Total abdominal hysterectomy and bilateral oophorectomy for all stages. Pelvic and a para aortic lymph node dissection. Omentectomy, resect all gross disease.
25
What is the chemotherapy for ovarian cancer?
Cisplatin and paclitaxel. It is sensitive.
Can provide neoadjuvant therapy to patients w/ disseminated disease involving the chest, and those who would not tolerate surgery.
26
What is the stomach cancer that has metastasized to ovary? What is shown on pathology?
Krukenberg tumor. Pathology shows signet rings
27
What is meige's syndrome?
Pelvic ovarian fibroma that causes ascites and hydrothorax
28
What is the most common malignant tumor in female genital tract?
Endometrial cancer
29
What are the risk factors for endometrial cancer?
Estrogen exposure - Nulliparity, late first pregnancy, obesity, tamoxifen; older women
30
What is vaginal bleeding in postmenopausal woman until proven otherwise?
Endometrial cancer
31
What subtypes of endometrial carcinoma have worse prognosis?
Serous and papillary
32
What nodes does cervical cancer go to first?
Obturator nodes
33
What types of HPV are associated with cervical cancer?
16 and 18
34
What is the most common type of cervical cancer?
Squamous cell
35
How do you cervical carcinoma?
Stage 1-2A: radical hysterectomy (includes upper vagina) w/ pelvic node dissection.
Stages 2-4: xrt
36
Where the stages of cervical cancer?
One: cervix
Two: upper two thirds of vagina
Three: pelvis, sidewall, lower one third of vagina, hydronephrosis
Four: bladder and rectum
37
What do you do with ovarian cysts in a post menopausal patient
If septated, has increased vascular flow on Doppler, has solid components, or has papillary projections - oophorectomy with intraoperative frozen sections; TAH if ovarian CA
38
What do you do with ovarian cyst in a premenopausal patient?
If septated, has increased vascular flow on Doppler, has solid components, or has papillary projections - oophorectomy with intraoperative frozen sections
39
What do you do with an incidental ovarian mass at the time of laparotomy for another procedure?
Postmenopausal - oophorectomy, frozen section, then TAH w/ BSOO and debulking if ovarian CA
Premenopausal patient - complicated
40
What do you do with abnormal uterine bleeding in a patient under 40?
Usually from anovulation. Treat with Medroxyprogesterone. If leiomyomas - GnRH
41
What do you do with abnormal uterine bleeding in a patient older than 40?
Usually from cancer or menopause - need biopsy
42
What are contraindications to estrogen therapy
Endometrial cancer, active thromboembolic disease, Undiagnosed vaginal bleeding, breast cancer
43
What can a uterine endometrial polyp present as?
Progressively heavier menses
44
What is caused by uterine fibroids?
Recurrent abortions, infertility, bleeding.
| Under hormonal influence.
45
What is the most common vaginal tumor?
Invasion from surrounding or distant structure
46
Appendicitis with pregnancy causes what?
Increased risk of premature labor and fetal mortality
| Need lap appendectomy: access 6cm above uterus, 10-15 mmHg insufflation
47
What is a hydatidiform mole?
Malignancy risk with partial mole; complete mole is of paternal origin. Treat with methotrexate
48
What do you get with toxic shock syndrome?
Fever, erythema, diffuse desquamation, nausea, vomiting. Associated with tampons left for a long time.
49
How do you diagnose and manage ovarian torsion?
Dx: dopppler US
Tx: One should detorse the ovary and assess viability at the time of surgery by gross visual inspection. Ovarian necrosis is rarely present at the time of surgery. A study showed that even women who had a bluish-black ovary at the time of surgery had normal follicular development when followed postoperatively.
50
What do you do with adnexal torsion with vascular necrosis?
Adnexectomy
51
What do you do with ruptured tubo-ovarian abscess?
Drainage
52
How do you diagnose ovarian vein thrombosis?
CT scan. Treat with heparin
53
What do you do with postpartum pelvic thrombophlebitis?
Heparin and antibiotics
54
Ovarian cancer tumor marker?
CA-125
55
Most common extra-colonic tumor in Lynch?
Endometrial cancer.
56
What is Fitz-Hugh-Curtis syndrome?
Uncommon following PID.
| Bacterial migration into peritoneum can cause inflammation and adhesions between the liver and the peritoneal lining.
57
Pt is undergoing a laparotomy for hysterectomy. She is having massive pelvic hemorrhage, which has not been controlled with standard measures. What can you do?
Ligation of the anterior branch of the hypogastric artery (internal iliac) will reduce pulse pressure to the pelvis, allowing control of hemorrhage. Collaterals will provide flow to prevent necrosis. Avoidance of the posterior branch is preferred due to decreased collaterals to the region.
58
Where can you find the ureter during a hysterectomy?
Medial aspect of the broad ligament.
59
A young lady undergoes laparoscopy for ovarian torsion. A mass is found and sent for frozen pathology. The frozen section of the right fallopian tube and ovary show an immature teratoma. What additional procedures are required to complete a fertility-sparing staging surgery?
Pelvic and para-aortic lymphadenectomy, omentectomy, peritoneal biopsies, and pelvic washings.
These additional procedures need to be performed for complete staging. Fertility-sparing surgery would be performed in a young female.
60
Risks for ectopic pregnancy.
Older age, cigarette smoking, PID, tubal ligation, in vitro fertilization.
61
Is there ever a role for sparing an ovary in cervical cancer?
A unilateral oophorectomy can be performed in women who have not completed childbearing if the patient has localized ovarian cancer. In women who have had all of their children, both ovaries should be removed.
62
Most common bacterial causes of PID?
Chlamydia trachomitis (greatest risk of infertility), Neisseria gonorrheae
63
Females with BRCA gene mutations should be counseled to have what risk-reducing procedure to prevent ovarian cancer?
Bilateral salpingo-oophorectomy at the completion of childbearing or by the age of 35 to 40 years.
Transvaginal ultrasound and cancer antigen 125, or CA-125, every 6 months is a reasonable option for women who have not completed childbearing.
Additionally, this prophylactic surgery also reduces the risk of breast cancer in these patients.
For breast cancer, they need mammograms alternated with breast magnetic resonance imaging scans every 6 months for heightened screening for breast cancer.
64
Ectopic pregnancy mgmt.
Medical management of ectopic pregnancy is preferred in hemodynamically stable patients with small ectopic mass sizes, serum beta-human chorionic gonadotropin less than 5000 mIU/mL, and no contraindications to methotrexate. A one-time dose of methotrexate has comparable efficacy and fertility outcomes to surgical intervention while avoiding postoperative complications. For women who wish to maintain the greatest possible fertility following treatment of ectopic pregnancy, salpingostomy is preferred to salpingectomy because both fallopian tubes are retained in salpingostomy.
65
Pregnant woman < 24 wks is having lap appy. What perioperative monitoring do you need for the baby?
Preoperative and postoperative fetal heart rate documentation. The pregnancy is previable (< 24 weeks); therefore, confirmation of fetal heart tones is sufficient before and after the procedure.
66
A staging total hysterectomy and bilateral salpingo-oophorectomy is performed for endometrial cancer, and the specimen is sent for frozen section. On frozen section, the tumor is found to be poorly differentiated endometrioid type, with deep myometrial invasion. What additional procedures are needed to complete the staging surgery?
Pelvic and para-aortic lymphadenectomy. Omentectomy is part of staging in patients with serous and clear cell tumors.
67
The most common complication following hysterectomy is?
Bladder injury.
Vaginal hysterectomy is associated with the fewest urinary tract complications, whereas robotic surgery is reported to have the highest. Adnexal surgery at the time of hysterectomy does not increase the risk of urinary tract injury.
68
What is the average fetal radiation exposure during a computed tomography scan of the abdomen and pelvis?
2.5 rad (0.025 Gy).
Although an abdominal ultrasound should be the first-line imaging technique, an abdominal computed tomography scan is not absolutely contraindicated. Pregnancy should not impede the use of necessary imaging studies for critical diagnoses.
69
For endometrial cancer, what factor is most likely to make you perform lymphadenectomy?
Tumor grade.
Lymphadenectomy is recommended with serous/clear cell/high-grade histology, myometrial invasion greater than 50%, and large uterine tumor measuring greater than 2 cm in diameter.
70
How are gynecologic malignant germ cell tumors staged?
The same way as epithelial ovarian tumors - surgically.
TAH/BSOO, pelvic and para-aortic LNDx, pelvic washings, omentectomy, and cytology of the diaphragm.
If the patient is premenopausal, you can perform fertility-sparing surgery. This includes unilateral salpingo-oophorectomy with preservation of the uterus and contralateral adnexa followed by staging - including LNDx, pelvic washings, and so on.
71
What are the normal cardiovascular changes during pregnancy?
Heart rate increased, stroke volume increased, mean arterial pressure decreased, and vascular resistance decreased.
Vasodilation occurs during pregnancy.
Elevated blood pressure during the second and third trimesters should be evaluated further because it may be a sign of developing preeclampsia.
72
A 30-year-old woman presents to the emergency department with complaints of acute onset of left lower quadrant pain. It is associated with nausea and vomiting. She has no vaginal bleeding. Transvaginal ultrasound identifies an adnexal mass. What is the most likely diagnosis?
Ovarian torsion.
73
Ectopic pregnancy typically occurs where?
fallopian tube; assn. w/ vaginal bleeding
74
Psx: acute lower abdominal pain, fever, chills, vaginal discharge, and an adnexal mass that is complex and multilocular. Dx?
Tubo-ovarian abscess
75
What is the best test to assess for the presence of a rectovaginal fistula?
Next test for surgical planning?
What patient function must be checked?
What is the ideal surgery?
Methylene blue tampon test - best sensitivity when done appropriately.
Rigid proctoscopy would be next. The quality of the rectal tissue (fibrosis, friability, etc.) and its associated compliance will help determine what type of operation should be performed. It also may help to localize the fistula.
Adequate anal sphincter tone and good performance status.
LAR w/ coloanal anastomosis and omental buttress +/- fecal diversion. End colostomy if poor sphincter tone. Loop sigmoid colostomy if poor performance status.
76
Discuss principles of management of intraop ureteral injury.
When ureteral injuries are detected intra-operatively, the injury should be repaired immediately. The location of the injury helps to determine what should be done.
In gynecology, many of the injuries happen at the pelvic brim or at the level of broad ligament where the ureter passes beneath the uterine vessels.
Repair Principles:
1. Debride.
2. Tension-free anastomosis and precise mucosal approximation and watertight closure (using interrupted 4-0 and 5-0 absorbable sutures).
3.Internal ureteral stents, in most cases (stenting is not mandatory, but typically used if the degree of transection approaches 50% of the ureteral circumference).
4. Isolation of repair with omentum or fat in patients at high risk for infection.
5. Retroperitoneal drainage.
77
What are options of ureter repair of intraop iatrogenic injury?
1. Primary closure of partial transection of the ureter: If a partial transection of the ureter from a scalpel or scissors is seen during operation, often primary closure can be accomplished.
2. Primary ureteroureterostomy: Any complete transection can often be repaired by primary ureteroureterostomy.
3. Ureteral reimplantation and psoas hitch: Injuries of the pelvic ureter in which the distal ureteral segment is of poor quality or of insufficient length are best-managed by ureteral reimplantation.
4. BOARI flap: The peritoneum is swept off the bladder dome, and a posteriorly based flap is created. The flap is folded back, a submucosal tunnel is developed in the flap and the ureteral reimplantation is completed. The flap is tubularized and closed in two layers.
5. Transureteroureterostomy: In cases of extensive pelvic ureteral loss where remaining proximal ureteral length is inadequate to allow reimplantation into the bladder, or concomitant significant ipsilateral pathology is present, a transureteroureterostomy may be considered. The recipient ureter is mobilized as little as possible to avoid any devascularization, and the injured ureter is brought under the mesentery above or below the inferior mesenteric artery, depending upon the degree of ureteral loss as well as the site selected for anastomosis Isolation and drainage: omental flaps the can be wrapped around the ureteral repair, providing physical isolation. Drains should be placed in the retro or extraperitoneal space.
78
How does antiphospholipid syndrome relate to gynecology?
These patients typically present with thrombosis and pregnancy-related complications (e.g., miscarriage). Infertility is not associated with APS.
79
What are some features of PCOS?
Common endocrine disorder in women. Although PCOS can lead to female infertility, other findings are also seen, including polycystic ovaries (on ultrasound), anovulation, increased androgen hormones (e.g., hirsutism, acne), and insulin resistance (e.g., obesity, type 2 diabetes).
80
Most common cause of rectovaginal fistula?
Obstetric trauma.
A rectovaginal fistula is classified as low if a repair can be done perianally and high if repair can be accomplished only transabdominally.
81
G1P1 female is 72 hours postpartum from a normal spontaneous vaginal delivery. She develops a fever of 38.6 °C (101.48 °F), left lower quadrant abdominal pain that radiates to her left groin, nausea, and vomiting. Bimanual exam reveals a rope-like mass in the left adnexa that appears to extend to the upper abdomen. How do you manage?
ABCs.
Dx: CT scan - thrombus in left ovarian vein.
- Septic pelvic thrombophlebitis
Tx: systemic heparin therapy and broad spectrum antibiotics for 7-10 days
82
Cullen's sign (superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus) can indicate what in a young female w/ vaginal bleeding, abdominal pain, and a positive pregnancy test?
Ruptured ectopic pregnancy
83
What tumor marker is used to monitor this patient for evidence of recurrent disease of her nonepithelial ovarian malignancy?
Inhibin - epithelial stroma tumors such as mucinous and endometrioid carcinoma and sex cord stromal tumors like granulosa cell tumor and Sertoli-Leydig cell tumor.
(serum CA 125 (normal 65 units/mL) - advanced epithelial ovarian cancer; not specific)
84
The presence of alpha fetoprotein with an ovarian neoplasm strongly suggests...
endodermal sinus tumor
85
CIN with mild dysplasia (CIN-1) usually 2/2 what? Mgmt?
Infection. This usually resolves and requires only followup.
86
CIN with moderate or severe dysplasia (CIN-2 or -3) discovered on colposcopic examination is better treated by?
destruction of the cells with cryoablation or a loop electrosurgical excision procedure (LEEP)
87
What gyn malignancy is associated w/ LDH?
Dysgerminomas (will have normal a-FP, maybe elevated B-hCG)
88
What is approved by the US Food and Drug Administration for monitoring response to therapy in women with known epithelial ovarian cancer?
CA-125
89
a-FP associated with what gyn cancers?
Yolk sac tumors, embryonal cell carcinomas and polyembryoma carcinomas, mixed germ cell tumors, and some immature teratomas
90
B-hCG associated with what gyn cancers?
Embryonal cell carcinomas and ovarian choriocarcinomas, mixed germ cell tumors, and some dysgerminomas.
91
Pelvic pain, dysmenorrhea (painful menses), dyspareunia (painful intercourse), and findings of nodule(s) in the posterior cul-de-sac (pouch of Douglas) are most suggestive of...
endometriosis - common, benign, estrogen-dependent disorder that results when endometrial glands and stroma occur at extrauterine sites
most common sites of endometriosis include the ovaries (US shows adnexal mass), posterior cul-de-sac (as in this case), uterus, and fallopian tubes
