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To Remember > Gen gyn > Flashcards

Gen gyn Flashcards

1
Q

Ultrasound findings of adenomyosis

A

Asymmetrical uterine wall thickening (posterior > anterior)

B Venetian blind appearance due to heterogeneous myometrium

C myometrial cysts

D disrupted endometrial/myometrial junction

E subEndometrial lines or thickening

F focal hyper school lines

V increased vascularity on Doppler

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2
Q

Definition adenomyosis

A

Endometrial tissue/glands within myometrium

Ectopic, non neoplastic endometrial glands and stroma, surrounded by hypertrophic and hyper plastic myometrium

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3
Q

Paediatric Gynae Hx

A

AGE of growth, thelarche, adrenache, menarche

Menstrual hx - duration, length, pain, assoc symptoms
Medical and surgical
-AN, birth, postnatal, milestones, chronic illness

Meds and allergies
Social hx - HEADS
Fam hx - age of puberty in parents/siblings
Specific symptoms- headaches, visual changes, galactosemia

Thelarche - breasts
Adrenarche - hair

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4
Q

Proven clinical benefits to HRT

A

Reduction vasomotor by 87%

Improvement in bone mineral density and reduced fracture risk

Reduction in colorectal cancer and endometrial cancer (combined only)

In women <60 or within 10 years of menopause, reduced coronary artery disease and stroke (with estrogen only HRT)

Reduced vaginal atrophy associated with improvement in: vaginal dryness, dyspareunia, discomfort, pruritis

Improved urinate symptoms of urgency and recurrent UTI

Reduced bone and muscle aches

Improved libido

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5
Q

Risks laparoscopic surgery

A

Immediate: pain, nausea, vomiting, bleeding during or after procedure, infection, blood clots, damage to internal surrounding organs, surgical emphysema (co2 trapped in skin), facial oedema
Anaesthetic risks

Long term: chronic pain, hernia (0.2-5%), scarring, scar pain, port site Mets

Organ/surgery specific pain

Other:nerve (sciatic, brachial), resp compromise, facial oedema, gas embolism, port site met

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6
Q

Risks to discuss when considering laparoscopic surgery to enhance fertility in people with endometriosis

A
  • whether lap surgery may alter the chance of future pregnancy
  • the possible impact on ovarian reserve
  • the possible impact on fertility of complications arise
  • alternatives to surgery
  • other fertility factors
  • non-fertility related benefits, such as pain management

Why offer: improved chance expectant pregnancy.
Offer lap ovarian cystectomy with excision cyst wall of endometriosis as this improves chance of pregnancy and reduces recurrence. Consider ovarian reserve

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7
Q

Why offer surgical management for endo ?

A

Improved chance of expectant pregnancy.

Offer excision of cyst wall of endometrioma, increases chance expectant pregnancy, reduces recurrence

Consider ovarian reserve

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8
Q

Incidence of dermoid complications

A

Tort 10%
Rupture 4% (0.2% chemical peritonitis)
Malignant transformation
Associated hyperthyroidism 20%

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9
Q

Bacteria involved in BV

A

GAMP

Gardnerella vaginalis
Atopboium species
Mobilincus species
Prevotella species

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10
Q

How HPV evades humoral system

A

Downregulates inflammatory micro-environment

Inhibits recruitment of langerhan cells and stromal dendritic macrophages

Inhibits ingress of effector T cells

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11
Q

How HPV vaccination works

A

Exudation of circulating neutralising antibodies into areas of epithelial micro-trauma, preventing adherence of virus to basement membrane and preventing infection basal cells

Vaccination aims to prevent HPV infection by inducing high and sustained levels of serum neutralising antibodies

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12
Q

Differentials for new vulval ulcer

A

Infectious
Non infectious

Infectious
-STI: hsv, syphilis primary chancre, chancroid (haemophilus), lymphogranula venereum

Noninfectious

  • Apthous ulcer: trauma, drug reaction
  • Inflammatory:dermatitis, lichen planus, lichen sclerosis
  • autoimmune: SLE, chrons, bullous pemphigoid
  • neoplastic: VIN, SCC, BCC
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13
Q

Components of vaginal discharge

A 
Cervical mucous
Bartholins and skene duct gland secretions
Vaginal wall transudate
Vaginal flora
Polysaccharides and glycogen
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14
Q

Physiological mechanisms preventing ascending pelvic infection

A

Cervix - narrow diameter, downward flow of mucus, IgA lysosomes
Endometrium - cyclical shedding
Uterotubal junction-mechanical barrier

Organisms ascend up through these barriers into usually sterile upper genital tract leading to endometritis, salpingitis, pelvic peritonitis

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15
Q

Passage of sperm

A

Seminiferous tubules, rete testis, epididymis, vas deferens, seminal vesicles, ejaculatory duct, urethra

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16
Q

Action of mifepristone and misoprostol

A

Mifepristone- anti progesterone, progesterone and glucocorticoid receptor antagonist. Progesterone required to support trophoblastic proliferation and ongoing pregnancy, mifepristone impairs implantation by encouraging decidual breakdown.

Misoprostol prostaglandin e1 agonist, naturally occurring Uterotonic. Acts on progesterone receptors on decides, myometrium and cx to increase softening and expulsion. Increased sensitivity of myometrium to pg 5x.

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17
Q

Risks of ART to MUM

A

Acute: cyst accident, OHSS, torsion

Pregnancy: GDM, poly, oligo, PTB, LBW. If fresh embryo: placental abruption/praevia/vasa praevia. Gest HTN. PPH + VTE

Long term: lifelong risk breat and ovarian not increased, but more likely to manifest breast cancer in 12 months following IVF cycle (same as preg or IVF), possible increase in borderline after FSH.

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18
Q

Risk ART for man

A

No long term risks, but oligospermia is associated with increased all cause mortality.
Semen quality is a biomarker for male somatic health, opportunity to intervene, or refer approrpiately (e.g. pituitary disease, testosterone deficiency), testicular cancer etc.

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19
Q

Risk of ART for child offsprin

A

Increase congenital defects, particularly with IVF/ICSI.

Epigenetic issues - increase in Beckwith Weidemann Syndrome and Angelamann (from 1 in 14k to 1 in 4k). I

Genetic - increased. Most common being Klinefelter Syndrome, may inherit congenital vas deferens or Y linked

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20
Q

URETERIC INJURY

A
  1. Enter pelvis, over brim @ level sacral promontory + bifircation common iliac –> likely when taking IP/oophrectomy
  2. PAsses beneath uterine arteries within the myometrium, 1.5cm lateral to cervix –> when taking the uterines
  3. Ureter tunnels within cardinal ligament toward trigone of bladder –> when taking cardinals and when suturing vault
  4. Ureter enters trigone obliquely –> during dissection of bladder off anterior lower uterus/cx in order to do colpotomy
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21
Q

Define overactive bladder

A

Combination of symptoms, sudden and compelling need or desire to pass urine, difficult to defer.

Can trigger involuntary loss of urine —> urge incontinence

22
Q

Benefits of HRT

A

Reduction in vasomotor symptoms by 80%

Improvement in bone mineral density and reduced fracture risk

Reduction in colorectal and endometrial cancer

In women <60 or within 10 years of menopause, reduces coronary artery disease and stroke

Reduced vaginal atrophy associates improvement in vagina dryness, dyspareunia, discomfort, pruritis

Improved urinary symptoms of urgency and recurrent UTI

Reduced bone and muscle aches
Improved libido

23
Q

Important to do at HRT conversation

A

Opportunity for routine health assessment and education

Breast
Cervical
CHD
Mental health
Bone density
24
Q

Management cutoffs for PUL

A

Expectant: HCG <1000, <35mm, stable, no FHR or free fluid, pain free

Either: HCG 1000-1500

Either MtX or surg: 1500-5000

Surgery: live, >5000, unstable, >35mm

Anti D 250 for surgery

FU hcg 2,4,7, weekly until result <20, if don’t drop by 15% review

25
Q

Investigations to assess tubal patency

A

Lap + dye

Hysteroscopy contrast synography (HyCoSy)

Hysterosalpingogram

26
Q

Pros and Cons HyCoSy

A

Outpatient, simulatneously with USS so can ass other pathology such as PCOS, reliable at exlcuding tubal occlusion, no risk of anaphylaxis to contrast, similar complications to HSG

High false positive rates. First line test in absence of known PID, endo, tubal

27
Q

Pros and cons HSG

A

Outpatient test, effective use of medical resources, no operative risks, reliable at excluding tubal occlusion, may increase fecundity,

CONS: risk of anaphylaxis to contrast, high false positive rate, first ine test in absence of known PID, endo, tubal disease

28
Q

Pros Cons Lap + dye insufflation of tubes

A

Direct vision of tubes, may increase fecundity, may diagnose concurrent pathology such as endo, is gold standard, advisable if known pelvic patho

Requires GA, surgicla procedure with risks of laparopscy, requires admisison to hospital, is expensive

29
Q

Brief summary of complications MCDA twins

A

TTTS from reduced AA anastamoses resulting in TOPS or TAPS

SFGR - unequal sharing and velamentous cord

Death of one twin, neuro disability or death of other twin, hypotension from vascular connections

INcreaesd risk of stillbirth despite intensive surveillance

30
Q

HEADSS

A

Home
Education, employment, eating, exercise
Activities, hobbies, pet relationships

31
Q

How does clomiphene work ?

A

Selective estrogen receptor modulator
BLOCKS action of oestrogen on receptor in hypothalamus and pituitary preventing negative feedback, therefore causing increased GNRH pulse frequency and release of FSH and LH, promoting follicular stimulation

Acts on ovarian receptors as an agonist, sensitising ovary to action of FSH, overall increased folliculogenesis, selective of dominant follicle, resulting in switch from positive to negative feedback at hypothalamus and pituitary, resulting in LH surge and ovulation

If no idea LMP, withdrawal bleed of provera first, then 50mg day 3-7, day 10 estrogen (no sec if too many follicles) then day 21 progesterone

32
Q

Benefits letrozole over clomiphene

A

Aromatase inhibitor

Reduced risk ovarian hyperstimulation
Reduced risk of mutiples
Increased live birth rates
Reduced SE headache, bloating, breast tenderness, flushing, abdo pain
Shorter half life ?less teratogenecity
33
Q

Palmers point

A 
Horizontal table, NG tube
3cm below inferior intercostal margin MCL
5mm incision along langerhans line
3 clicks (int/ext oblique, peritoneum) 
Saline drop, opening pressures
Low flow then up to 20
5mm port, scope, 360 review
34
Q

Main electrosurgical injuries

A

Lateral thermal - high voltage or time activated, damaging bowel or other

Direct coupling - non target tissue being damaged but another instrument touching active one

Capacitance coupling - spreading across plastic or metal ports

Insulation failure - microbreakages
Direct injury

35
Q

Etiology BV

A

Disruption of normal flora, loss of lactobacilli which normally maintain acidic environment resulting in overgrowth anaerobes,

36
Q

Cohort study

A

Observational study where participants grouped according to their exposure compared to group without exposure and followed up prospectively

Expensive, time consuming, not randomised, may have allocation bias, not good for rare outcomes, differential loss to follow up

37
Q

Where ureter vulnerable

A

During dissection of the infundibulopelvic ligament which is just overlying where the ureter passes over the pelvic brim

During ligation of the uterine arteries

During dissection of the cardinal ligaments off the posterior aspect of the cervix

During dissection of the bladder of the anterior lower uterine segment and vagina where the ureteters pass posteriorly into trigone.

Securing of the vaginal angles when closing the vaginal vault.

38
Q

Benefits of ovarian drilling

A

Can improve ovulation rates
Concurrent assessment of pelvis
No risk of OHSS

Risks
Infection
Haematoma
Reduced ovarian reserve

39
Q

USS findings cs scar ectopic

A

Empty uterus

Gestational sac or solid mass of trophoblast at level of internal os, negative sliding sign

Thin or absent myometrial layer between sac and bladder

Prominent trophoblastic/placental circulation

Empty endocervical canal

40
Q

USS findings cervical ectopic

A

Empty uterus
Barrel shaped cervix
Absence of sliding sign
Blood flow around gest sac using doppler

41
Q

USS tubal ectopic

A

Inhomogenous/non cystic adnexal mass 50-60% cases moving separate to ovary, “tubal ring” bagel sign

Empty gestation sac 20-40%

Collection of fluid in up to 20% cases/pseudo scac

42
Q

USS findings IUP

A

Double decidual sign

43
Q

What do E6 and E7 ?

A

Most oncogenic proteins of HPV, bind to p53 and pRB and inhibit their cell regulation actions, leading to proliferation of HPV virus

44
Q

What factors lead HPV to persist and progress to cervical cancer ?

A

Environmental - smoking
Sexual exposure - parity, multiple partners, early debut
Immunosuppressive - HIV, transplant recipients
Long term systemic steroid use

45
Q

Health consequences of sexual asault

A

REPRODUCTIVE - gyn trauma, unintended pregnancy, unsafe abortion, sexual dysfunction STIs

MENTAL health - depression, PTSD, anxiety, sleep difficulties, somatic complaints, suicidal behaviour, panic

BEHAVIOURAL - high risk (unprotected, earyl debut, multiple partners), high risk of prepetrating or experiencing subsequent sexual violence

FATAL - death from suicide, pregnancy complications, unsafe abortions, aids, murder rape or for honour

46
Q

Difference between cut and coag

A

CUT - continuous, low voltage, high frequency. Coaptation and vaporisation. Less thermal spread.

COAG - intermittent, high voltage, low frequency. Desication and fulgaration. High lateral spread. More likely to have capictative coupling (i.e. onto another conductor/metal port)

47
Q

Tamoxifen effects on tissues

A

ENDOMETRIUM
Cystic dilated glands with condensed peri-glandular stroma, atrophic overlying epithelium , increased incidence polyps

RR 4 of endometrial carcinoma
1.6% with 5 years

Promotes endometrium, growth fibroids, endometriomas, vaginal epithelium

ANTI estrogen @ breast, but PRO estrogenic VTE, bone, endometrium

Washout 1/12 prior to pregnancy

48
Q

When to undertake urodynamics

A 
Useful for counselling
Failed conservative/medical management
If suggestion of overactive bladder or stress induced detrusor overactivity
If anterior wall prolapse present
Previous incontinence surgery 
Neurological conditions
49
Q

Factors that contribute to genuine SUI

A

Obstetric - episiotomy, forceps, multiparity
Elevated BMI
Post menopausal
Raised intrabdo pressure - chronic cough, constipation
Lifestyle - heavy lifting
Prev gyn surgery

50
Q

4 differentials for mixed urinary

A

Stress with hypermobile urethra
Urge from detrusor overactivity
Recurrent uti
Urinary retention with overflow

To Remember (10 decks)

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