General GYN Flashcards
What is the difference between anal incontinence and fecal incontinence?
Anal incontinence: loss of flatus with or without stool
Fecal incontinence: recurrent involuntary loss of solid/liquid stool from the rectum
How common is fecal incontinence?
What are causes and risk factors?
7-15%.
Causes:
- increased parity
- higher order perineal laceration
- chronic constipation
- incomplete repair of 3rd/4th degree laceration
- pelvic floor weakness
- Neurologic: spinal cord injury, CVA
- Non-neurologic: more common. Lacerations, IBD, chronic diarrhea, constipation w/ overflow, rectal prolapse/hemorrhoids, systemic dz (DM, urinary incontinence)
What are risk factors for fecal incontinence?
What are meds associated with it?
obesity, smoking, increased age, hx anal intercourse, chronic illness, increased parity, hx 3rd/4th degree laceration, use of forceps, midline episiotomy
Meds associated with loose stool/fecal incontinence: antibiotics (fluoquinolones, cephalosporins), prostaglandins (hemabate/misoprostol), laxatives, metformin
What is the treatment for fecal incontinence?
correct underlying issue. PFPT, pads/diapers, dietary changes (identify triggers), adjust meds, anti-diarrheal, sacral nerve stimulation or surgery.
Which distension media are available:
Electrolyte-containing: LR, NS. Cannot use with monopolar bc they conduct electrical current.
- max deficit is 2500
Electrolyte-poor:
Dextrose, glycine, sorbitol, mannitol (not metabolized=iso-osmolar).
- can cause hyponatremia if large volume used.
- deficit is 1500L
How would you evaluate a confused/disoriented pt after hysteroscopic myomectomy?
Concern for hyponatremia, pulm edema (Crackles), fluid overload w/ hyponatremia. Vitals w/ O2 sats. Stat CBC, BMP, CXR. Check op report for fluid deficit
If electrolyte imbalances, correct those.
If crackles on exam, CXR w/ pulm edema, start diuretic
What fluid deficit would concern you? 1000 for glycine/sorbitol/mannitol.
How would you manage the patient with hyponatremia after hysteroscopy?
Admit for observation for fluid overload and hyponatremia (due to use of hypo-osmotic fluid media or non-electrolyte fluids if using electrosurgical monopolar energy)
Check for hyperammonia (if 3% glycine used as opposed to Sorbitol or Mannitol for fluid media)
Can still have significant fluid volume overloads using isotonic fluids with bipolar energy resectoscopes as well
Follow I&Os, place Foley catheter
Give Lasix to begin diuresis
Check electrolytes, especially sodium – If low, start NS. If significantly low sodium (<110) consider 3% saline given very slowly to replace
- replace sodium slowly 1-2mEq/hr.
Pulse oximetry, if <90% consider CXR, diureses
Follow neurological symptoms; seizures, CNS changes
How would patient present if you used isotonic fluid?
How could you prevent this in future procedures?
Fluid overload (CHF). Less common w/ electrolyte abnormalities.
Hyponatremia is more common w/ hyper-osmolar fluids. So use NS or LR. Limit surgery to less than 1 hr. Monitor the quantity of fluid absorbed, limit IVF. Max is 2500, stop sooner if pt older.
Risks of hysteroscopy: uterine perforation, hyponatremia, infection, creating false passage.
Discuss the steps of a hymenectomy
When is hymenectomy indicated?
Dorsal lithotomy position, perineum prepped draped. stellate/cruciate incision to open hymen. Gentle irritation. Hymenal tags grasped w/ tissue forceps. Each hyental tag elevated and excised at introital level. Base sutured w/ interrupted 3-0 synthetic absorbable suture.
See steps of transverse vaginal septum!!!
Indicated if imperforate hymen (causing hematocolpos) or perforated hymen w/ hymenal hypertrophy obstructing intercourse (can cause hemorrhage 2/2 lateral pudendal artery).
Oliguria after TAH w/ EBL 2L and transfusion.
What diagnostic studies would you order and why?
CBC, BMP.
- Cr to evaluate for kidney injury to rule out AKI (>1.0).
- Orthostatics.
- UA (muddy brown casts)
- FeNA. pre-renal <1.0. ATN >2.0. 1-2 is inconclusive.
- Renal US.
What is ATN and how is it diagnosed and treated?
Loss of concentrating ability. Early finding.
- Renal ischemia (most common causes), sepsis, nephrotoxins.
- Ischemic ATN lasts 7-21d, return to baseline usually. Diuretics don’t help renal perfusion.
- Supportive management w/ adequate perfusion, avoid hypovolemia. Discontinue nephrotoxic meds, non-contrast imaging only. May require temporary dialysis.
What are causes of oliguria?
Pre-renal: IVF resuscitation.
Intrinsic renal issue
Post-renal obstruction
How do patients with necrotizing fasciitis present?
What antibiotics cause it?
What is management?
Infection of deep soft tissues, progressive destruction of muscle, fascia. Muscle tissue spared 2/2 good blood supply.
2/2 E. Coli, Klebsiella, enterococci, clostridium, bacteroides
Erythema w/o sharp margins, edema, severe pain out of proportion to exam, fever, crepitus, necrosis
Labs: nonspecific.
Diabetes and trauma increase risk
Broad spectrum antibiotics (vanc/zosyn), to OR for debridement as this is a surgical emergency. Can lead to limb loss/death. Early recognition=critical.
What is GTD?
Gestational trophoblastic disease
- spectrum of cell proliferations arising from placental villous trophoblast:
1. Hydatidiform mole (complete and partial)
2. Invasive mole
3. Choriocarcinoma
4. Placental site trophoblastic tumor (PSTT)
Describe a partial vs complete mole
PARTIAL
- karyotype 69 XXX or 69 XXY
- maybe fetus present
- uterine size SGA
- rare theca-lutein cysts
- GTN risk rare (<5%)
COMPLETE
- karyotype 46 XX or 46 XY
- absent fetus (on villi w/ POCs)
- LGA uterine size
- common theca lutein cysts (2/2 high hCG levels0
- GTN risk 15-20%
*molar pregnancies associated w/ associated w/ anemia, infection, hyperthyroid and coagulopathy
When is there concern for post molar GTN?
If post evacuation HCG levels plateau at 10-20 mIU/ml. What is your management?
increasing hcg >10% across 3 values
Plateauing hcg 4 measurements within 10% of each other across 3 weeks.
Plateau at low levels is consistent with “phantom HCG”, which are nonspecific heterophilic antibodies. They are not excreted in the urine, so check a UPT to exclude a false + HCG before subjecting patient to chemotherapy for GTN.
What is treatment of molar pregnancy?
- Suction D&C + sharp curettage or hyst if no desired fertility
- HYST if: age <40, S>D, hCG >100K, bilateral theca lutein cysts >6cm (bc all incr risk GTN)
- early US for all future pregnancies (recurrence risk 1% after 1 and 15% after 2 prior moles)
Post-op follow up:
- reliable contraception
- weekly HCG until negative (for partial stop when first negative obtained, for complete once neg, do monthly x 3 mo)
What is GTN?
What is the treatment?
gestational trophoblastic neoplasia. Malignant proliferation of placental trophoblastic tissue
- invasive mole, choriocarcinoma, placental site trophoblastic tumor, epithelioid trophoblastic tumor
- FIGO staging system (first 3 are indicators of hcg level)
- age
- duration from prior pregnancy
- type of prior pregnancy (abortion vs full term)
- pre-treatment HCG level
- largest tumor size
- site/number of mets
- history of failud chemo
Treatment:
- single agent MTX vs. actinomycin d for low-risk disease.
- multiagent EMACO (etoposide, MTX, actinomycin d, cyclophosphamide, vincristine) for high risk
How would you manage black implants in posterior cul de sac on laparoscopy?
management of implant disease.
- remove small implants but avoid managing advanced disease (implants near bowel serous, vascular structures or ureter)
- I would remove implants using bipolar cautery or excision biopsy.
- Post op management: suppression w/ OCPs, progestin only methods, LN-IUD
What are indications for inpatient management of PID?
- acute peritoneal signs on exam
- pregnancy
- failure of outpatient management
- TOA
- pt inability to comply w/ outpatient management
- pt N/V and unable to tolerate oral meds
What should you consider when choosing an abdominal incision?
Prior operation w/ suspected adhesion/scarring
Presence of large mass in operative field
Body habits
- prior operation w/ graft (hernia repair) in area of incision
What are entry options for laparoscopy if prior midline incision?
- Hasson: create periumbilical incision to permit dissection of periumbilical fascia and pre-peritoneal tissue under direct visualization. stay sutures placed in umbilical fascia to secure port and maintain pneumoperitoneum.
- Veress needle + diag lac port away from area of prior incision in LUQ (palmer’s point is 3cm below left costal margin in mid-clavicular line).
- for hyst: lower quadrant ports 2cm medial and superior to ASIS, lateral to border of rectus. injury to inferior epigastric=most common vascular injury.
**small bowel=most commonly injured in laparoscopy.
What are different suture materials?
- rapidly absorbable (gut) - dissolves within3 -4 weeks
- minimal tensile strength. use when need rapid clearance. - Delayed absorbable (vicryl): tensile strength 5-6wks but lose 50% of it by 2 weeks. absorption by hydrolysis.
- PDS (polydioxanone) - more tensile strength to 10-12 weeks. good for if have delay in healing.
- Permanent (nylon, prolene): retains tensile strength for 2 months. unaffected by local chemical environment.
What are types of wound classification
- Superficial separation (anterior to rectus fascia) - hematoma/seroma
- Fascial dehiscence - loss of primary integrity
- Complete dehiscence (including peritoneum)
- Evisceration (mortality rate 10-30%) - failure of abdominal closure
Evisceration: surgical emergency. oR for exploration and closure. protect bowel by enclosing in wet towel. Get Cx. prophylactic abx. deride all layers, irrigate w/ 4L sterile saline.
- close incision w/ through and through sutures of permanent (nylon, prolene) suture at 2cm intervals, allow space for drainage.
- close skin with staples
- NGT until return of bowel function. TPN to allow proper healing.
Technique to decr risk of wound issues:
- period abx (Redose if EBL>1.5L or surgery >4hrs)
- clipper shavings
- chlorexidine prep
- short hospital stay
How do you manage uterine perforation?
look at site w/ hysteroscopy. low threshold for laparoscopy
- if perforated w/ cervical dilation or blunt instrument, low risk vascular injury, observation reasonable.
- if signs severe bleeding or vascular/visceral injury suspected, abdominal and cervical exploration needed.
- if perforated w/ electrosurgical energy, morcellation or suction curettage, could have serious injury and need laparoscopy.
If broad ligament hematoma on laparoscopy: if vein, observation or direct pressure. if expanding, laparotomy, apply direct pressure, blood products, vascular surgery consult.
IF uterine vessel injured, attempt uterine artery ligation (O’leary): 0-vicryl start low on lateral uterus medial to ascending uterine artery through myometrium from anterior to posterior and then back posterior to anterior through avascular portion of broad ligament.
- can consider IR embolization.
What can cause diffuse bleeding with D&C for missed AB?
- uterine perforation or injury to uterus/cervix
Retained products in cavity - abnormal placentation (molar pregnancy)
Management: look for laceration, sharp curettage for retained tissue. uterotonics (methergine or hemabate bc Pit not effective at early gestational age), uterine tamponade w/ foley or bakri ballon.
What is management of vulvar hematoma?
risk of internal injury
- tx: ice packs, pain meds, Foley catheter if unable to urinate.
- external exam, vaginal speculum, pelvic bimanual to see mass effect, CT if concern for internal issue.
- consider EUA if necessary.
- don’t open/explore a contained hematoma.
What is the Bovie?
What is the Gyrus/Ligasure?
What is the harmonic?
Bovie: high frequency monopolar electrical current. instrument is one pole and patient’s body is the other.
Ligasure/gyrus: bipolar cautery with cutting device. tissue cauterized and then divided. can have lateral thermals spread.
Harmonic: uses ultrasonic energy by vibration to cause protein denaturation. less effective for hemostasis.
What are risk factors for GTD (Gestational trophoblastic disease)?
Extremes of maternal age
Asian population
Type A blood group
Prior molar pregnancy
Primiparous
Would you correct a uterine septum at the time of hysteroscopy if didn’t know about it beforehand?
NO! if you don’t have accurate MRI/US, need laparoscopy first to rule out bicornuate or arcuate uterus.
- otherwise could resect through top of uterus and cause bowel injury
What are recommendations for graft use?
mesh graft erosion complications in 5-20% of case series!
- reserve mesh for high risk pts
- benefits > risks for: recurrent prolapse, anterior compartment, significant comorbidities & can’t have extensive procedure
- only if surgeon experienced/trained
- careful counseling
What are complications of mesh graft use?
- Incontinence procedure related: UTI, unmasking urge incontinence, urinary retention
- bleeding/hematoma
- chronic pelvic pain
- dyspareunia
- fistula formation
- graft infection
- delayed graft erosion
- vaginal discharge/odor.
Management: observe, pelvic rest 6-8wks, vaginal estrogen, office excision of mesh (40% effective), OR excision of mesh (90% effective).
- excision: dissect overlying epithelium, excise/remove mesh, close epithelium, cysto to r/o bladder erosion.
What is diagnosis of rectovaginal fistula?
- uncontrolled passage of gas/feces from vagina
- malodorous vaginal discharge
- fecal soiling on undergarments
- visually see large fistulas. small fistulas visualized with:
– Instill saline in posterior vagina and add air into rectum which leads to “bubbling” OR methylene blue + lubricant in anterior rectal wall and see if blue staining in vagina.
How do you repair RV fistula?
(dentate line) is a line which divides the upper two-thirds and lower third of the anal canal. above line=high fistula. below=anovaginal or low fistula.
Pre-op: immediate or wait 3-4mo for inflammation, estrogen cream if postmenopausal, abx, liquid diet, bowel prep.
Procedure:
- mobilize adjacent tissue plants
- excise fistulous tract
- place many layers f intervening tissue between 2 cavities involved in fistula. DON’T overlap suture lines.
- multi-layered closure (without tension, avoid ‘dead space’
Suture material: tension-bearing layers 2-0 vicryl, non-tension bearing 3-0 vicryl
What is the differential diagnosis for vaginal fluid drainage after hyst/pelvic floor procedure?
What is workup?
FISTULA
- Vesico-vaginal fistula
- Uretero-vaginal fistula
- Recto-vaginal fistula
Urinoma drainage from ureteral injury
Incomplete closure of vaginal apex.
Physiologic leukorrhea or vaginitis
NEXT STEP:
- identify etiology and manage that etiology.
- Dual tampon dye test:
1. place tampon in vagina, instill methylene blue mixed w/ saline into bladder, check tampon. If tampon=blue, vesicovaginal fistula.
2. If tampon clean, drain bladder and place new tampon. Give oral phenazopyridine (analgesic). If tampon=orange, ureterovaginal fistula. - Cysto
- Retrograde pyelography: ureteral integrity
- IVP: less useful.
What is management of vesico-vaginal fistula?
- Conservative: foley decompression 4-6w. If failed to heal, continue foley for 12wks total (allow for inflammation/induration to resolve).
- Surgical repair: 3-layer closure technique
- excise fistula tract
- re-approximate bladder submucosa w/ 3-0 vicryl
- re-approximate bladder muscularis with 2-0 vicryl
- close vaginal mucosa.
What is management of uretero-vaginal fistula?
Cysto (exclude bladder involvement) and CT urogram (identify site of ureteral injury)
- lower ureter injury site fistula (distal 15cm): foley stenting. If fails to heal, ureteroneocystotomy. CT urogram 2-3wks post op.
- High ureteral injury: percutaneous neph for renal decompression. surgical repair at 12wks.
What is the differential diagnosis for abdominal pain and fever?
What is initial workup?
- Pregnancy related (ectopic pregnancy, septic AB)
- non-gyn (appendicitis, pyelonephritis, diverticulitis, cholecystitis, pancreatitis, pneumonia)
- sepsis due to any of above
- Gyn: PID, TOA
Workup: H&P
- CBC, CMP, amylase/lipase, HCG, GC/CT, UA/UCx, BCx
-imaging depending on results of H&P: US, CTAP, renal US, CXR
what is the treatment of PID and TOA?
Ceftriaxone 1g q24 + doxy 100mg PO/IV BID + flagyl 500mg PO/IV BID
OR
amp 2g VI q6 + gent 2mg/kg load (then 1.5mg/kg q8) + clinda (900mg IV q8)
How do you manage pt w/ TOA not improving with IV abx?
start conservative: antibiotics for 48-72hr.
- IR drainage or surgery
- immediate IR drainage/surgery IF: if large abscess (>7cm), ruptured abscess, sepsis, or postmenopausal (risk malignancy)
Treatment failure:
- new onset/persistent failure
- worsening abdominal pain
- enlarging pelvic mass
- persistent/worsening leukocytosis
- suspected sepsis.
How would you surgically manage TOA?
laparotomy w/ midline vertical incision
- drainage abscess/remove necrotic tissue. Get Cx for aerobes and anaerobes.
- irrigate pelvis (2-3L)
- inspect for additional collections
- evaluate for origin of abscess (i.e. ruptured appendicitis)
- if unilateral TOA, do USO. if desired fertility, make sure other adnexa is in good condition.
- place closed suction drainage
- use delayed absorbable suture on fascia (PDS - retains tensile strength for 3 months), NO suture on subQ.
What causes fluid overload in hysteroscopy?
- rapid instillation of fluid under pressure in open vessel in myometrium (usually vein) occurs toward base of myoma under resection. also occurs w/ endometrial ablation
- intraperitoneal instillation of fluid (transfallopian drainage of fluid under pressure)
- unrecognized uterine perforation
- electrolyte poor fluids (sorbitol, mannitol, glycine).
Complications w/ operative hysteroscopy:
- uterine perforation
- bleeding from intracavitary operative site
- thermal injury to extra-uterine structures
- air embolism
- intravascular fluid overload of hysteroscopic solution.
How do you minimize fluid overload with hysteroscopy?
- obtain baseline Na and Hgb
- use low pressure fluid system w/ continuous monitoring of fluid balance. assess fluid deficit q3-5 mind during procedure
- limit operative time to 45 min
- use empiric diuretic if large fluid deficit (lasix 20mg)
- Na <120=high risk seizure. Replete w/ 3% NaCl SLOWLY to maximum of 150cc.
- electrolyte poor fluid: overload can occur at deficits of 500-1000 mL, more likely to occur if comorbidities (heart/renal dz and older age).
- electrolyte-containing fluid: stop at 2500mL.
What are factors associated with regret for tubal ligation?
- age <30
- recent decision to have BTL (< 6 mo)
- unstable relationship
- unhealthy children
- immediate postpartum BTL
- postpartum with: neonate w/ low agars, significant prematurity, sick neonate
What are types of SSI and risk factors for SSI?
Pre-op measures to decrease risk?
- superficial incisional infection
- deep incisional infection
- pelvic or vaginal cuff cellulitis
- pelvic/vaginal abscess
RF:
- BMI>30
- preoperative hyperglycemia
- nutritional status
- current infection at other site
- smoking
- BV
- subQ>3cm
- MRSA
- immunosuppression
Pre-op measures:
- identify/treat any other infections (skin or UTI)
- don’t shave incision site (use clippers)
- optimize glycemic control
- base w/ antiseptic
- skin prep w/ alcohol-based agent, vaginal prep w/ iodine
- abx within 1 hr of incision
- good operative/antiseptic techniques
What procedures need Ancef and which need doxy?
Ancef
- all hysts, colporrhaphy, vaginal slings, laparotomy
Doxy:
- HSG/chromopertubation if PID or abnormal tubes (100mg BID x5d
- surgical abortion or pregnancy related D&C: doxy 200mg IV once pre-op.
*use Ancef 3g if >120kg
What are recommended antibiotics if PCN allergy or MRSA?
PCN
- if anaphylaxis (NO cephalosporin)
- clinda 900mg q6 or flagyl 500mg + gent 5mg/kg ONCE
MRSA: vang 15mg/kg single dose
What is management of 8cm complex cyst w/ hx endometriosis?
H&P, US, tumor markers only if concern for malignancy
- surgical eval w/ lsc.
- evaluate primary lesion, evaluate opposite ovary/tube, full pelvic surgery and staging assessment of endometriosis
- pelvic washings if neoplasm suspected.
- if endometrioma –> cystectomy (if asymptomatic and less than 5cm, expectant management in general).
- if neoplasm, laparotomy for removal of lesion intact
What are types of abdominal incisions?
Vertical/midline:
- best exposure, quick entry, decreased blood loss and nerve damage, easily extended, WOUND DEHISCENCE MORE COMMON.
Transverse: Langer’s lines are lines of skin tension. less tension, excellent strength/cosmesis, decreased ability to extend.
– Pfannenstiel: separate sheath from rectus.
– Joel-Cohen: minimization of sharp dissection=quick entry. less pain/operative time/fever
–Maylard: transect rectus muscle w/ ligation of inferior epigastric. don’t separate sheath from rectus.
Best way to differentiate between type 0, 1, and 2 fibroids?
Best way to differentiate between type 2 and 3?
Between type 4 and 5?
Sonohystogram bc percentage of submucosal component varies.
Hysteroscopy (contact with endometrium)
MRI - intramural component with or without submucosal
What factors are associated with increased risk of uterine leiomyomas?
Factors associated with DECREASED incidence?
When do fibroids regrow:
Family hx, black race, age, premenopausal, HTN, obesity.
Use of OCP, increased parity
3-9 months after cessation of treatment.
Ideal position for laparoscopy?
Correct placement of trochars?
Layers that trochar goes through during sub umbilical entry?
Through palmers entry?
dorsal lithotomy, with trunk/thigh angle of 170 degrees, hip abduction < 90 degrees.
Can transilluminate to identify superficial epigastric.
Skin, subQ fat, rectus fascia, peritoneal fat, peritoneum
Skin, subQ fat, outer fascia layer, muscle, inner fascial layer, peritoneum.
What is the course of the ureter?
KNOW THIS
Ureter courses along psoas muscle, enters pelvis at bircurfaction of common iliac. Passes to medial leaf of broad ligament. Passes medial/anterior to internal iliac. Passess under uterine artery 1.5cm LATERAL to cervix and courses into trigone.
