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General GYN Flashcards

1
Q

What is the difference between anal incontinence and fecal incontinence?

A

Anal incontinence: loss of flatus with or without stool
Fecal incontinence: recurrent involuntary loss of solid/liquid stool from the rectum

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2
Q

How common is fecal incontinence?
What are causes and risk factors?

A

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)

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3
Q

What are risk factors for fecal incontinence?
What are meds associated with it?

A

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

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4
Q

What is the treatment for fecal incontinence?

A

correct underlying issue. PFPT, pads/diapers, dietary changes (identify triggers), adjust meds, anti-diarrheal, sacral nerve stimulation or surgery.

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5
Q

Which distension media are available:

A

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

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6
Q

How would you evaluate a confused/disoriented pt after hysteroscopic myomectomy?

A

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.

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7
Q

How would you manage the patient with hyponatremia after hysteroscopy?

A

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

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8
Q

How would patient present if you used isotonic fluid?

How could you prevent this in future procedures?

A

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.

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9
Q

Discuss the steps of a hymenectomy
When is hymenectomy indicated?

A

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).

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10
Q

Oliguria after TAH w/ EBL 2L and transfusion.
What diagnostic studies would you order and why?

A

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.

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11
Q

What is ATN and how is it diagnosed and treated?

A

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.
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12
Q

What are causes of oliguria?

A

Pre-renal: IVF resuscitation.
Intrinsic renal issue
Post-renal obstruction

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13
Q

How do patients with necrotizing fasciitis present?
What antibiotics cause it?
What is management?

A

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.

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14
Q

What is GTD?

A

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)

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15
Q

Describe a partial vs complete mole

A

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

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16
Q

When is there concern for post molar GTN?

If post evacuation HCG levels plateau at 10-20 mIU/ml. What is your management?

A

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.

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17
Q

What is treatment of molar pregnancy?

A
  • 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)

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18
Q

What is GTN?
What is the treatment?

A

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

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19
Q

How would you manage black implants in posterior cul de sac on laparoscopy?

A

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

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20
Q

What are indications for inpatient management of PID?

A
  • 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
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21
Q

What should you consider when choosing an abdominal incision?

A

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

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22
Q

What are entry options for laparoscopy if prior midline incision?

A
  1. 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.
  2. 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.

23
Q

What are different suture materials?

A
  1. rapidly absorbable (gut) - dissolves within3 -4 weeks
    - minimal tensile strength. use when need rapid clearance.
  2. Delayed absorbable (vicryl): tensile strength 5-6wks but lose 50% of it by 2 weeks. absorption by hydrolysis.
  3. PDS (polydioxanone) - more tensile strength to 10-12 weeks. good for if have delay in healing.
  4. Permanent (nylon, prolene): retains tensile strength for 2 months. unaffected by local chemical environment.
24
Q

What are types of wound classification

A
  • 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

25
Q

How do you manage uterine perforation?

A

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.
26
Q

What can cause diffuse bleeding with D&C for missed AB?

A
  • 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.

27
Q

What is management of vulvar hematoma?

A

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.

28
Q

What is the Bovie?
What is the Gyrus/Ligasure?
What is the harmonic?

A

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.

29
Q

What are risk factors for GTD (Gestational trophoblastic disease)?

A

Extremes of maternal age
Asian population
Type A blood group
Prior molar pregnancy
Primiparous

30
Q

Would you correct a uterine septum at the time of hysteroscopy if didn’t know about it beforehand?

A

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

31
Q

What are recommendations for graft use?

A

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
32
Q

What are complications of mesh graft use?

A
  • 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.

33
Q

What is diagnosis of rectovaginal fistula?

A
  • 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.
34
Q

How do you repair RV fistula?

A

(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

35
Q

What is the differential diagnosis for vaginal fluid drainage after hyst/pelvic floor procedure?

What is workup?

A

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.
36
Q

What is management of vesico-vaginal fistula?

A
  1. Conservative: foley decompression 4-6w. If failed to heal, continue foley for 12wks total (allow for inflammation/induration to resolve).
  2. Surgical repair: 3-layer closure technique
  3. excise fistula tract
  4. re-approximate bladder submucosa w/ 3-0 vicryl
  5. re-approximate bladder muscularis with 2-0 vicryl
  6. close vaginal mucosa.
37
Q

What is management of uretero-vaginal fistula?

A

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.
38
Q

What is the differential diagnosis for abdominal pain and fever?
What is initial workup?

A
  • 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

39
Q

what is the treatment of PID and TOA?

A

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)

40
Q

How do you manage pt w/ TOA not improving with IV abx?

A

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.

41
Q

How would you surgically manage TOA?

A

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.

42
Q

What causes fluid overload in hysteroscopy?

A
  1. 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
  2. intraperitoneal instillation of fluid (transfallopian drainage of fluid under pressure)
  3. unrecognized uterine perforation
  4. 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.

43
Q

How do you minimize fluid overload with hysteroscopy?

A
  • 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.
44
Q

What are factors associated with regret for tubal ligation?

A
  • 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
45
Q

What are types of SSI and risk factors for SSI?
Pre-op measures to decrease risk?

A
  • 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

46
Q

What procedures need Ancef and which need doxy?

A

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

47
Q

What are recommended antibiotics if PCN allergy or MRSA?

A

PCN
- if anaphylaxis (NO cephalosporin)
- clinda 900mg q6 or flagyl 500mg + gent 5mg/kg ONCE

MRSA: vang 15mg/kg single dose

48
Q

What is management of 8cm complex cyst w/ hx endometriosis?

A

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
49
Q

What are types of abdominal incisions?

A

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.

50
Q

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?

A

Sonohystogram bc percentage of submucosal component varies.

Hysteroscopy (contact with endometrium)

MRI - intramural component with or without submucosal

51
Q

What factors are associated with increased risk of uterine leiomyomas?
Factors associated with DECREASED incidence?

When do fibroids regrow:

A

Family hx, black race, age, premenopausal, HTN, obesity.

Use of OCP, increased parity

3-9 months after cessation of treatment.

52
Q

Ideal position for laparoscopy?

Correct placement of trochars?

Layers that trochar goes through during sub umbilical entry?
Through palmers entry?

A

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.

53
Q

What is the course of the ureter?

A

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.

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