Fertility and prolapse Flashcards
Retained products of conception- definition, symptoms and diagnosis
Definition: when pregnancy related tissue i.e. placental tissue or fetal membranes remain in the uterus after delivery. It can also occur after miscarriage
Symptoms: vaginal bleeding, abnormal vaginal discharge, lower abdominal or pelvic pain, fever.
Diagnosis= ultrasound
Retained products of conception: management
- Remove them surgically
- ERCP: the cervix is gradually widened using dilators and the products are manually removed using vacuum aspiration and curettage (scraping).
- The two complications are Endometritis and Asherman’s syndrome
Subfertility- basic investigations
- Semen analysis
- Serum progesterone 7 days prior to expected next period i.e. day 21
- Chlamydia screening, BMI, rubella immunity in the mother
Subfertility- key counselling advice
- Folic acid 400mg
- Aim for BMI 20-25
- Regular sexual intercourse every 2 to 3 days
- Smoking/drinking advice
When to start investigations for infertility
Investigations and referral for infertility should be started when the couple has been trying to conceive for 12 months. This can be reduced to 6 months if the women is older than 35 as her ovarian stores are likely to be already reduced
Causes of subfertility
- Sperm problems (30%)
- Ovulation problems (25%)
- Tubal problems (15%)
- Uterine problems (10%)
- Unexplained (20%)
Female hormone testing involves
- Serum LH and FSH on day 2 to 5 of the cycle
- Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
- Anti-Mullerian hormone
- Thyroid function tests when symptoms are suggestive
- Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
Female hormone testing results
- High FSH suggests poor ovarian reserve
- High LH suggests PCOS
- A rise in progesterone on day 21 indicates that ovulation has occurred
- Anti-Mullerian hormone, high levels suggest good ovarian reserve. Can be measured any time in the cycle
Further fertility investigations, often performed in secondary care (female)
- Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
- Hysterosalpingogram to look at the patency of the fallopian tubes
- Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
Semen analysis
After 2 days of sexual abstinence but no more then 7 after. Repeat at 3 months, earlier if grossly abnormal. The semen sample needs to be complete and if not the man should report this, should be delivered to lab within an hour.
Secondary infertility treatment in men
1) Microbiology tests
2) Sperm culture
3) Endocrine tests
4) Imaging of the urogenital tract
5) Testicular biopsy
Assisted pregnancy techniques
- IUI- intrauterine insemination
- In vitro fertilisation
- ICSI= Intra-cytoplasmic sperm injection
- In females Gonadotrophins or Clomiphene citrate to induce ovulation
- Pro-nuclear transfer: 3 parents baby, done if the mother is carrying a mitochondrial disease
Utero-vagina prolapse
Due to weakening and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
Types of prolapse
- Uterine: when the uterus descends into the vagina
- Vault: in women that have a hysterectomy and no longer have a uterus, the top of the vagina (the vault) descends into the vagina
- Rectocele: defects in the posterior vaginal wall which cause the rectum to prolapse forwards into the vagina, associated with constipation
- Cystocele: defects in the anterior vaginal wall, causing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both bladder and urethra I called cystourethrocele
Prolapse- risk factors
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age, postmenopausal
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation
Prolapse- symptoms
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
Grading using the pelvic organ prolapse quantification
- Grade 0: Normal
- Grade 1: The lowest part is more than 1cm above the introitus
- Grade 2: The lowest part is within 1cm of the introitus (above or below)
*Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended - Grade 4: Full descent with eversion of the vagina
Surgery for uterine prolapse
- Vaginal hysterectomy: traditional treatment, not often effective
- Hysteropexy, open or laproscopic: the uterus and cervix are attached to the sacrum using a bifurcated non-absorbable mesh
Vaginal vault prolapse treatment
1) Sacrocolpexy, which can be laproscopic or open, fixes the vault to the sacrum using a mesh. Complications include mesh erosion and haemorrhage.
2) Sacrospinous fixation is performed vaginally and suspends the vault to the sacrospinous ligament. Complications include nerve or vessel injury, infection and buttock pain. It is less effective but recovery is faster.
Vaginal wall prolapse
Anterior and posterior ‘repairs’ are used for the relevant prolapse but, as several prolapses may occur in one patient, these operations are often combined.
Surgery for urodynamic stress incontinence
If this is present, the tension-free vaginal tape (TVT), transobturator tape (TOT) procedures, or Burch colposuspension may be performed at the same time as prolapse repair.
Prolapse investigation
Speculum
What does cervical cancer screening involve
- HPV primary screening and if this is positive then LBC is analysed
- Liquid based cytology (LBC) to detect early abnormalities of the cervix which if untreated can lead to cancer of the cervix
- Cervical screening is not a test for cancer
- Colposcopy to diagnose cervical intraepithelial neoplasia (CIN) and to differentiate high grade lesions from low grade abnormalities in women with abnormal cytology
Management of results: negative hrHPV
Return to normal recall unless:
* the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
* the untreated CIN1 pathway
* follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
* follow-up for borderline changes in endocervical cells
Management of results: positive hrHPV
- Samples are examined cytologically
- If the cytology is abnormal -> colposcopy
Abnormal cytology results
- borderline changes in squamous or endocervical cells.
- low-grade dyskaryosis.
- high-grade dyskaryosis (moderate).
- high-grade dyskaryosis (severe).
- invasive squamous cell carcinoma.
- glandular neoplasia
If the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
- if the repeat test is now hrHPV -ve → return to normal recall
- if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
- If hrHPV -ve at 24 months → return to normal recall
- if hrHPV +ve at 24 months → colposcopy
Smear test: If the sample is inadequate
- repeat the sample within 3 months
- if two consecutive inadequate samples then → colposcopy
Individuals who’ve been treated for CIN1, CIN2 or CIN3 should be invited 6 months after treatment for a test of cure. Repeat cervical sample in the community.
Treatment of CIN
- Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic.
- Cryotherapy- in low grade CIN
- Hysterectomy- persistent disease in women nearing/after menopause or after LETZ
Colposcopy
Done if cervical screening finds HPV. A speculum is inserted into the vagina to open it. A microscope is used to look at the cervix in greater detail, the microscope stays outside the body. An endocervical brush is used to take a sample of further testing. Grades of CIN have characteristic appearances when stained with 5% acetic acid, the diagnosis is only confirmed histologically and therefore biopsy is useful,
Exceptions for routine cervical screening
- 25 to 64 with renal failure requiring dialysis must haver cervical cytology after diagnosis
-All women with HIV should have cervical surveillance, annual cytology should be performed with an initial colposcopy - In organ transplant recipients
HPV
Cervical cancer is mostly caused by HPV 16,18 which causes 70% of cervical cancer
Malignant disease of the cervix investigations
- To confirm the diagnosis, the tumour is biopsied.
- To stage the disease, vaginal and rectal examination is used to asses the size of the lesion and parametrial or rectal invasion.
- Unless it is clearly small, examination under anaesthetic is performed. Cystoscopy detects bladder involvement and MRI detects tumour size, spread and LN involvement.
- To assess the patient’s fitness for surgery, a CXR, FBC, U&Es are checked. These may be abnormal with advanced disease. Blood is cross-matched before surgery
Cervical intraepithelial neoplasia (CIN) staging
- CIN 1 – changes only in lower 1/3rd of squamous epithelium, low grade, but changes can be difficult to differentiate from reactive changes only. spontaneous regression rates are over 50% in about 22 months.
- CIN 2 and 3 – changes in lower 2/3 rd and whole of the squamous epithelium respectively. Higher grade abnormality, regression rates are lower.
- CIN 2 – regression rate is 50% to 60%, therefore in nulliparous women conservative management can be offered with more regular surveillance.
- CIN 3 – treatment options offered as further progression leads to cancer.
HPV vaccine
- Offered to all 12-13 year old, cut cervical cancer by 90%
- Current brand: Gardasil 9 covers HPV 6, 11, 16, 18, 31, 33. 45, 52
Oligohydramosis
In oligohydramnios there is reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
Causes of oligohydramosis
premature rupture of membranes
Potter sequence
bilateral renal agenesis + pulmonary hypoplasia
intrauterine growth restriction
post-term gestation
pre-eclampsia
Hyperemesis gravidarum grading score
PUQE score
Trichomoniasis?
Bubbly thin, fishy discharge with strawberry cervix
Caused by a parasite
Investigations= High vaginal swab, Urethral swab, First void urine
Treatment: Metronidazole
Cephalexin
- UTI antibiotic
- MoA: Cephalosporin, prevents cell wall formation. Fights -ve and +ve
- Side effects: Agranulocytosis, Eosinophilia, GI upset, Neutropenia, Thrombosytopenia
Trimethoprim
- UTI antibiotic
- Contraindications: blood dyskaryosis
- Side effects: Diarrhoea, Electolyte imbalance, Fungal overgrowth, Agranulocytosis
Nitrofurantion
- UTI antibiotic
- Contraindication: Infants <3 months
VTE and anaemia- contraindications
Low molecular dose heparin- major trauma, haemophilia or other haemorrhagic diseases, thrombocytopaenia, peptic ulcer
Ferrous sulphate- causes constipation
Compression stockings- peripheral artery disease, neuropathy, suspected DVT, infection or trauma
Tibolone
- Used in postmenopausal treatment of osteoporosis and endometriosis as well as HRT
- Synthetic hormone
- Side effects: acne, increased hair growth
- Contraindications: acute porphyrias, arterial thromboembolic diseasen
Gender scan
16 weeks onwards
Contraindications of HRT
- History of breast cancer
- History or high risk of venous or arterial thromboembolic disease, stroke and cardiovascular disease. Progesterone only preparations are preferred
- Uncontrolled hypertension
What is the criteria for expectant management of an ectopic i.e. no intervention
Follow up needs to be possible to ensure successful termination
Ectopic needs to be unruptured
Adnexal mass <35mm
No visible heart beat
No significant pain
hCG <1500
What is given to women prior to having surgery for ectopics or miscarriage?
Prostaglandins (misoprostol)
What Endometrial polyps
Small, usually benign, tumours
Occurs in the endometrium - endocrine tissue in origin
Common in 40-50 year olds when oestrogen is high
Medication which increases chance of them being found- Tamoxifen
Signs/ symptoms: Menorrhagia, Intermenstrual bleeding, Possible prolapse through cervix
How are endometrial polyps investigated and treated
USS (transvaginal)
Hysteroscopy
Treated- Resection using diathermy or avulsion
