General gynae Flashcards
Heavy menstrual bleeding
Definition = Menstrual bleeding of abnormal quantity, duration or schedule in a non-gravid woman of reproductive age
Causes = PALM COEIN (polyps, adenomyosis, leiomyomas, malignancy or hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified)
History, examination, investigations (FBC, coags, ferritin, androgens, oestrogen, LH/FSH, TFT, pelvic US, HSG, hysteroscopy)
CAUSES AS PER TABLE
Intermenstrual and postcoital bleeding
Causes = benign, polyp, STI, genital tract malignancy
IMB
Persistent IMB should have cotest (HPV and LBC), TV US and refer to Gynaecologist - RANZCOG guidelines
Causes include contraceptive or hormonal therapies
PCB
Persistent PCB should consider STI and cervical cancer - RANZCOG guidelines
Single episode of PCB with normal CST and normal appearing cervix does not need urgent referral but persistence and recurrence does need referral
Most common presenting symptom for Chlamydia
Electrosurgery
• Household current:
o Much lower frequency (¬60kHz) – this causes excessive neuromuscular stimulation
• Electrosurgical current:
o Much higher frequency(¬200khz) – above the threshold for muscular stimulation (which is ¬100khz)
• Cut = low voltage, high frequency, high current
• Coag = high voltage, low frequency. Low current
Waveform Surgical Mode
Vaporisation Cut Non contact
Fulguration Coag Non contact
Desiccation Either cut/coag Contact
MECHANISMS OF ELECTROSURGICAL INJURY
• Direct thermal injury: unintended activation of the electrode while touching an unintended target
• Direct coupling: touching of two instruments creating either a local arcing effect, or activating one of the instruments itself – injury may occur outside the field of view
• Capacitive coupling: where two conductors are separated by an insulator, with no way for the current to dissipate
• Insulation failure – damage to the instrument delivering current, so that the current escapes elsewhere rather than the point of the instrument
Ovarian torsion
Background: most (75%) cases <30yrs
Pathophysiology:
- The ovary torts around the infundibulopelvic ligament and the utero-ovarian ligament causing reduced arterial and/or venous flow
- Usually involves tube and ovary
- Usually precipitated by cyst or tumour
- More common >5cm mass
Risk factors:
- Age
- Ovarian/tubal mass (dermoid most likely type of cyst causing torsion)
- Pregnancy - increases rate 5x
- Assisted conception/ovulation induction and OHSS
- Previous pelvic surgery
- Developmental anomalies - long fallopian tube
Clinical presentation:
- Acute, sudden onset, pelvic pain
- Nausea/vomiting
O/E:
- Localised peritonitis
- Mass on bimanual exam
Ix:
- TV US → ovarian mass, “midline anterior ovary” (normally lateral to uterus), internal haemorrhage, free fluid, lack of blood flow (however doesn’t exclude torsion due to dual blood supply of ovarian and uterine arteries and can have intermittent torsion), “whirlpool sign” which is twisting of pedicle
- bHCG to exclude ectopic
Management:
- Laparoscopy + detorsion +/- cystectomy
- Salpingo-oophorectomy in postmenopausal women, suspicion of malignancy or if severe necrosis/peritonitis
- Benefit to keeping ovary even if black/blue - does get reperfusion
- >36hrs delay causes significant congestion and necrosis
- If ovarian torsion occurs with normal ovary, can perform oophoropexy (suturing ligament to lateral pelvic wall)
Complications:
- Ovarian infarction and necrosis
- Peritonitis
- Miscarriage
PCOS
Symptoms: irregular menses, hirsutism, acne, obesity, infertility, alopecia
DDx: CAH (do morning 17-OH levels), Cushing’s syndrome, androgen secreting tumours, steroid abuse
Rotterdam criteria (2 of 3):
- Oligo or anovulation
- Clinical (acne/hirsutism) or biochemical hyperandrogenism (recommended to use FAI which is testosterone/SHBG x100)
- Polycystic ovaries (>12 follicles 2-9mm or ovarian volume >10mL)
AND exclusion of other causes of hyperandrogenism
Ferriman-Gallway score: 9 areas of hair growth graded 0-4; score >8 is hirsutism
Ix:
- LH>FSH
- High FAI, low SHBG
- High oestrogen, day 21 progesterone (anovulatory), FSH, prolactin
- TV US if abnormal bleeding: ET<7mm unlikely to be hyperplasia
- Thickened ET or polyp → endometrial biopsy /hysteroscopy
Management:
- Conservative: weight loss, diet changes, exercise (first line)
- Medication: COCP, progesterone and withdrawal bleed every 3-4months, metformin (although no evidence insulin sensitising agents give any longterm benefit), ovulation induction (clomiphene - SERM which competes for oestrogen receptors → hypothalamus sees low circulating levels of oestrogen → less negative feedback → GnRH increases → FSH increases → folliculogenesis → oestrogen rise → LH surge → ovulation)
- Surgery: bariatric surgery, ovarian electrocautery (cauterise/destroy ovarian tissue to promote ovulation)
Complications:
- Metabolic syndrome
- Insulin resistance/T2DM
- Cardiovascular disease
- Endometrial hyperplasia or malignancy
- Infertility
- Hypertension
- Dyslipidaemia
- OSA (CPAP improves insulin sensitivity)
- Depression/anxiety
Ovarian torsion questions
2013 Feb and 2018 July - Question 6
a. List 5 epidemiological or predisposing factors that may be associated with an increased risk of ovarian torsion. (5 marks)
Presence of ovarian cyst > 4cm
Dermoid tumours most commonly implicated
Malignancy unlikely to tort (due to adhesions)
History of ovarian hyper-stimulation
Theca lutein cysts and expansion of ovarian volume
Polycystic ovary
Reproductive age women (mostly < 30yo)
Pregnancy (1st trimester) – enlarged corpus luteum cysts + laxity of supporting structures in pregnancy
More commonly torsion on the right (mobility of left ovary limited by sigmoid colon)
Development abnormalities: excessively long fallopian tube, absent mesosalpinx
Previous pelvic surgery (tubal ligation)
A 26 year old nullipara presents to the Emergency Department with vomiting and acute onset severe left sided lower abdominal pain of 6 hours duration. She is 9 weeks gestation with an IVF pregnancy. Transvaginal ultrasound on admission shows “a left sided 8 cm ovarian mass with features highly suggestive of ovarian torsion”. The intrauterine pregnancy is viable and consistent with dates.
b. With respect to the ultrasound findings of “a left sided 8 cm ovarian mass with features highly suggestive of ovarian torsion”,
i) Describe 3 ultrasound features commonly associated with ovarian torsion. (3 marks)
- Heterogenously enlarged ovary
- Presence of peripheral follicles “string of pearls”
- Midline ovary
- Free fluid in pouch of Douglas
- Twisted pedicle - ‘whirlpool sign’ (uncommon)
- Asymmetric thickening of ovarian wall cysts
- Colour doppler: enlarged ovary with absence parenchymal perfusion
ii) Discuss 2 limitations with ultrasound diagnosis of ovarian torsion. (2 marks)
- Delay in treatment → ability to preserve the ovary by de-torting an ovary at surgery is time dependent; awaiting USS diagnosis may delay proceeding to surgery
- Obese - unable to see ovaries
- If not sexually active - cannot do TVUS
- Highly dependent on operator
- Not sensitive nor specific → USS does is not 100% sensitive nor specific for ovarian torsion
- Not being able to see blood flow to the ovary on USS does not necessarily diagnose ovarian torsion
- Reporting the presence of blood flow does not necessarily exclude ovarian torsion
- In early stages, may have continued arterial flow with blockage of venous flow
- Some USS findings are non-specific (eg: FF, enlarged ovary)
You perform a laparoscopy 3 hours after she presented to the Emergency Department. The ovary is blue/black and twisted 1-3 times around the infundibulopelvic and utero-ovarian ligaments.
- *c. Justify your decision to preserve this ovary at surgery. (5 marks)**
- Most likely still viable - intraop assessment of viability is poor
- Young/pre-menopausal
- Pregnant - may be corpus luteum cyst so if removed may require progesterone treatment to maintain pregnancy if <12wks gestation
- Preserve ovarian function - in studies with ultrasound follow-up, the rate of follicular development after detorsion was 80 percent or higher. Serum AMH may also be higher in patients with a history of ovarian torsion managed with detorsion compared with unilateral oophorectomy.
- Keeping ovaries has lower risk of intraop complications, same risk of sepsis/VTE
- Unlikely to be malignant so no requirement to remove for histopath diagnosis
Ectopic pregnancy
Defintion:
- Extrauterine pregnancy
- Mostly in fallopian tube but can also be abdominal, caesarean, ovarian, interstitial (proximal fallopian tube), heterotopic etc
- 15% recurrence risk for salpingostomy; 8% for salpingectomy or methotrexate
Presentation:
- Asymptomatic
- Vaginal bleeding
- Abdominal pain
- Haemodynamic instability and acute abdomen (ruptured)
Risk factors:
- Previous ectopic
- Tubal surgery
- Tubal ligation
- PID
- IVF pregnancy
- IUD
- Smoking
- In utero DES exposure
- 50% have no risk factors
Examination:
- Abdominal tenderness, localised peritonism
- PV bleeding
- Haemodynamic instability (tachycardia, hypotension)
- Shoulder tip pain (diaphragmatic irritation by blood in peritoneal cavity)
Ix:
- Quant bHCG
- TV US - adnexal mass, empty gestational sac, gestational sac with yolk sac and no FHR, or live ectopic if bHCG>1500, fluid in POD (but not diagnostic), pseudosac (in 20% of ectopic), sliding sign (adnexal mass moving separately to ovary)
- TA US - if unstable to look for blood in abdomen
- Blood group
- FBC
- UEC/LFT - for methotrexate
Complications:
- Tubal rupture
- Unstable woman
Follow up:
- Serial bHCG (every 48-72hrs)
If rising ≥35% - could be normal IUP, need more tests
If rise <35% - non-viable pregnancy
Plateauing or decreasing hCG - non-viable/failed pregnancy
EXPECTANT
Criteria for expectant:
- Stable, no signs of rupture
- Asymptomatic
- bHCG<1500 and declining
- mass <3.5cm
- Close to ED and will represent if deteriorates
Follow up:
- Twice weekly bHCG + weekly TV US
METHOTREXATE
- 90% success - similar to salpingectomy
- Succes rate: bHCG < 1000 = 98%, 1000 – 5000 = 95%, 5000 – 10,000 = 86%
- 7% risk of tubal rupture
- Can give for ectopics in fallopian tube, cervix, interstitial (may need higher doses), CS
- No effect on ovarian reserve or fertility
- No Hx of subfertility → no difference in reproductive outcomes with treatment
- Hx of subfertility → expectant or medical Mx has improved reproductive outcomes compared to surgical
Criteria for treatment:
- Haemodynamically stable
- No CI to methotrexate (viable IUP, ruptured ectopic, renal or liver disease, immunodeficiency, allergy, breastfeeding)
- No abdominal pain
- Size <3.5cm
- bHCG ≤5000
- No fetal heart
- No IUP
- Able to attend post-treatment follow up appointments and have access to ED
Dose:
- Dose is 50mg per meter squared
- Single dose usually - same success rate as double dose and less side effects
- Second dose given day 7 if drop in bhCG is <15% between day 4 and day 7
- bHCG can rise day 1 to 4 - this can be normal
- Then repeat bloods after day 7 weekly if ≥15% decline from day 7 to 14, repeat weekly until negative
- If <15% drop on day 14, consider third dose
- If levels not declining to 0 consider new pregnancy and repeat TV US
- Interstitial and cervical pregnancies may need multiple doses
- Can have mild abdominal pain after dose due to tubal abortion but monitor for severe pain
Success rates - better success if:
- bHCG<1000
- No gestational sac
- Small increase in bHCG 48hrs after first dose MTX
Precautions:
- Contraception - avoid pregnancy for 3 months
- Avoid pelvic exams due to risk of tubal rupture
- Avoid sunlight due to methotrexate dermatitis
- Avoid folic acid
- Avoid NSAIDs - due to renal excretion of methotrexate and NSAIDs and theoretical risk of toxicity
- SE of methotrexate: stomatitis, conjunctivitis, gastritis, abnormal LFTs, bone marrow suppression, neutropenia
SURGERY
Indications:
- Haemodynamic instability
- bHCG>5000
- Mass >3.5cm
- Live ectopic
- Contraindications to methotrexate
- Failed methotrexate
- Non-compliant or poor access to follow up
- Heterotopic/coexistant viable IUP
Salpingostomy - incise fallopian tube and remove ectopic gestation
Salpingectomy - remove fallopian tube, preferred over salpingostomy if there is a healthy contralateral tube (RCOG)
Salpingectomy vs salpingostomy
- Salpingectomy: adv - reduces risk of ovarian cancer starting in fallopian tube, does not require serial bHCG afterwards
- Salpingostomy: adv - preserves tube; disadv - higher rate of retained gestational tissue, need weekly hCG until negative, may require further surgery or MTX anyway
- Same rates of future pregnancies and of repeat ectopics in both
FIRST LINE TREATMENT
Caesarean section - surgery
Interstitial - medical if stable
Ovarian - surgery
Abdominal - surgery
Heterotopic - surgery (lap removal of ectopic), MTX if nonviable IUP or not wanting pregnancy
Caesarean scar ectopic
Definition:
- Implantation of early gestation in hysterotomy incision from previous CS
Type 1 - implantation on scar tissue itself
Type 2 - implantation in the defect or niche left behind by incomplete healing of incision
Risk factor:
- Previous CS
- Previous MROP
- Previous D&C
Presentation:
- Vaginal bleeding
- Abdominal pain
- Asymptomatic
Ix:
- Empty uterus
- Enlarged hysterotomy scar with embedded mass (placenta, gestational sac)
- Thin or absent myometrial layer between gestational sac and bladder
- Vascular appearance near area of CS scar (trophoblastic tissue)
- Empty endocervical canal
DDx:
- IUP
- Cervical ectopic
- Placenta accreta spectrum
Management: (surgery preferred)
- Wedge resection (open, TV, lap) - remove scar and reapproximate uterus
- TV US guided aspiration
- Intragestational injection of methotrexate +/- uterine artery embolisation (avoid systemic MTX)
- If not wanting uterus, hysterectomy
- Expectant Mx uncommon due to risk of complications
Follow up:
- Expectant or MTX - need weekly bhCG until negative
- Early dating US for future pregnancies
- Consider earlier delivery in future from 34-36wks (due to risk of uterine rupture)
Recurrent miscarriage
Definition:
- 2 or more failed clinical pregnancies (on US or histopath) OR
- 3 consecutive pregnancy losses (can be extrauterine) to same partner
OR
- 1 or more second trimester miscarriage
- Risk of miscarriage 15%, at least 1 miscarriage with 2 pregnancies is 30%, with 3 pregnancies is 45% etc
Primary - never had live birth
Secondary - had previous livebirth, better prognosis
Risk factors:
- Previous miscarriage
- Uterine anomaly e.g. septaste
- Genetics
- Aneuploidy
- Thrombophilia - factor V Leiden mutation, prothrombin mutation, protein S deficiency, factor XII deficiency specifically (not antithrombin or protein C)
- Medical conditions - poorly controlled diabetes (well controlled does not increase risk)
- Infections (BV, chlamydia, gonorrhoea) - (Greentop - TORCH not RF)
- Hyperprolactinaemia
- AMA
- Intrauterine adhesions
- Submucosal fibroids
- Cervical insufficiency (midtrimester not early loss)
- PCOS
- Thyroid disease
- Untreated coeliac disease
- Smoking
- Obesity
- Radiation
- Male factor - abnormal sperm
History:
- History of all previous pregnancies
- Gynae Hx - CST, cycles
- Medical Hx
- Family Hx
- Social Hx - smoking, EtOH
Ex:
- General physical exam
- Signs of endocrinopathy - hirsutism, galactorrhoea
- Pelvic exam
Ix:
- TVUS - uterine anomalies, renal anomalies
- HSG
- Hysteroscopy - for intrauterine pathology (adhesions, septum)
- Thombophilia screen - lupus anticoagulant, anticardiolipin Ab - done twice, 12wks apart (can be elevated with viral illness), no evidence for ANA
- TSH and TPO-Ab
- Karyotype - for translocations or mosaicism if all above investigations normal
Mx:
- Lifestyle modifications - weight loss, cease smoking, reduce EtOH/caffeine
- Genetic abnormality → karyotype + IVF/PGD
- Uterine anomaly → surgery
- APLS → aspirin + UF heparin (or clexane) increases live birth/reduce miscarriage rate
- Diabetes → better BSL control
- Thyroid disease → treat
- Hyperprolactinaemia → bromocriptine
No evidence for progesterone (RANZCOG), aspirin or heparin (unless APLS), clomiphene, glucocorticoids, metformin, IvIg
- *SPIN study – Scottish Pregnancy Intervention Study, Blood 2010**
- *-** Multicentre RCT of women with unexplained recurrent miscarriage
- Compared: (1) aspirin & LMWH to (2) monitoring
- Found NO difference in pregnancy loss rates (both around 20%)
- *ALIFE study – Anticoagulants for Living Fetuses Study, NEJM 2010**
- *-** RCT un-blinded trial of 364 women with unexplained recurrent miscarriage
- Compared (1) placebo, (2) aspirin or (3) aspirin + heparin
- Found NO difference in live birth rates
Miscarriage
Definition: pregnancy loss up to 20wks; 12% of those with bleeding have miscarriage; likely due to chromosomal abnormalities
Types of miscarriage:
- Incomplete - open cervix, some POC in uterus
- Complete - closed cervix, no POC with previously confirmed IUP
- Missed - closed cervix, nonviable IUP
- Threatened - closed cervix, viable IUP
- Septic - signs of sepsis
Risk factors:
- Previous miscarriage
- Age - maternal and paternal
- Medical conditions - obesity, diabetes, thrombophilias, hypo and hyperthyroidism
- Uterine anomalies
- Fibroids distorting cavity
- Substance use
- Smoking, alcohol
- Medications - e.g. teratogens, NSAIDs
- Stress
- Trauma
- CVS or amniocentensis
- Second trimester - cervical insufficiency, fetal anomaly, PPROM, preterm labour, abruption, hydrops
Presentation:
- Bleeding
- Pain
- Nausea/vomiting
- Loss of pregnancy symptoms - e.g. breast tenderness
- Signs of sepsis - uterine tenderness, purulent discharge, hypotension, tachycardia, fever
Ix:
- Spec
- bHCG (should see GS TV>1500, TA>2000)
- Pelvic US
- G+H (anti D if ≥ 8wks)
- FBC
Criteria for diagnosis (all TV US:
- CRL ≥7mm* without cardiac activity - *CRL is most accurate
- MSD ≥ 25mm without fetal pole or yolk sac
- ≥ 11 days after GS with yolk sac but no embryo with FHR
- ≥ 14 days after GS without yolk sac or embryo with FHR
- No embryo on follow up US
Management:
- Patient centred - involve in decision
- However some may be CI or safer for that patient than others
EXPECTANT
- 70-80% efficacy within 14days
- Complications: pain, bleeding, infection, RPOC, need follow up (US or bHCG), failure, DIC (rare, if prolonged)
MEDICAL
- Preferred for uterine anomalies or those who want to avoid uterine instrumentation
- Recommend mife + miso - higher efficacy if both than miso alone (90 vs 75%)
- Given mife 200mg PO then 24hrs later, miso 800microg Bucc/SL/PV
- May need repeat miso 800microg dose 12-24hrs later
- Above if for 1st trimester - for 2nd trimester it is mife 200mg PO then 24hrs later 800microg Bucc/SL/PV every 3hrs until delivery (dose varies with uterine scar) and should be in hospital
- Follow up in 2 weeks with repeat US or bHCG
SURGICAL
- Preferred if on anticoagulation so can time surgery or those who want immediate treatment or suspected molar
- D&E with pre-op misoprostol for cervical ripening if ≥13wks
- Recommend pre-op antibiotics
- Avoid curettage as it increases risk of uterine perforation
- Does not require follow up tests
Complications:
- Heavy bleeding/haemorrhage
- Infection
- Sepsis
- RPOC
- Asherman’s syndrome
- Depression/anxiety/PTSD from loss
Offer contraception if not wanting pregnancies, even IUD at time of surgery
Management with any 3 (expectant/medical/surgical) does not change likelihood of lifebirth in next pregnancy
MIST trial - expectant vs medical vs surgical
Medical:
- Incomplete miscarriage – misoprostol 800 microg PV
- Early fetal demise – mifepristone 200mg po, then misoprostol 800 microg PV 24-48hrs later
- D&C offered if expulsion of RPOC had not started within 8 hours of misoprostol administration
Outcome: no difference in infection rates within first 14 days between all 3 and more unplanned admission/unplanned D&C after expectant and medical Mx; no difference in anxiety/depression in all 3; more analgesia in expectant than other 2
MIST 2 trial - type of treatment does not affect subsequent fertility, 80% of women had livebirth within 5years of miscarriage
RANZCOG:
- No evidence progesterone prevents miscarriage for unselected women in 1st trimester
- Some evidence that in threatened miscarriage with IUP AND a hx of previous miscarriage, it reduces spontaneous miscarriage (also in NICE, prog 400mg BD until 16wks)
- in ART, progesterone results in significantly higher pregnancy rate than no treatment/placebo
Miscarriage questions
Jan 2020
- *Miscarriage**
- *38 yo P0 with no symptoms, TV US showed CRL 6mm with no fetal heart. GP told patient non-viable pregnancy and needs D&C and referred to you.**
a) Evaluate the GPs response/plan (3)
- Check complete history – has previous US been done that show no interval growth or if fetal heart was present
- Confirm EDD/LMP
- Check medical history, previous miscarriages
- If only single US, does not meet criteria for miscarriage as CRL needs to be at least 7mm or show no interval growth
- Recommend repeating ultrasound in 11 days and if no interval growth or still no fetal heart, then can recommend management including expectant, medical or D&C
b) What is your management (1)
- Repeat ultrasound and review in at least 11 days
- *Eventually goes on to have miscarriage diagnosis. Patient adamant wants expectant management.**
- *c) Based on landmark trials counsel her on 8 important points (8)**
- MIST trial – no difference in infection rates in first 14 days between expectant management, medical management and surgical management; only increase in needing D&C and unplanned admission after expectant and medical management
- MIST 2 trial – type of treatment does not affect subsequent fertility as 80% of women had livebirth after miscarriage
Counselling points:
- Expectant management involves waiting for spontaneous expulsion of products of conception
- Successful in 70-80%
- Will review again in 2 weeks for appointment with follow up ultrasound to check for RPOC or can repeat bhCG
- In other 20-30%, may require medical management or surgical management which is D&C
- Medical management has 80-90% success and surgical has up to 97% success rate
- Expectant and medical more risk of bleeding but no change in Hb drop
- Bring in products of conception to check for histopathology diagnosis of miscarriage
- If having heavy bleeding or pain, need to come to emergency department and may require emergency D&C
- Need to live close to emergency facilities for this management
- Need to come for follow up, but don’t need to follow up for surgical management
- Also offer support and social work as diagnosis of miscarriage can be traumatising
- Simple analgesia
- Anti D if rhesus negative
After 2 weeks of expectant management US shows persistent gestational sac. Wants medical management
d) How does addition of mifepristone increase likelihood of successful management?
- Progesterone antagonist that blocks progesterone action so pregnancy stops progressing
- Misoprostol is prostaglandin analogue to cause uterine contractions to expel products
- Synergically work to expel miscarriage
e) Mifepristone action
- Progesterone antagonist that blocks progesterone action so pregnancy stops progressing
- *f) Medical management regime and dosing (mife + miso)**
- Mifepristone 200mg oral then 24hrs later 800microg misoprostol vaginal (less SE), buccal/sublingal and miscarriage should occur within 24-48hrs of medication
- To review 2 weeks post medication with repeat US for RPOC
Oct 2020
Recurrent miscarriage
A 38 year old G3 P0 woman presents with a history of three (3) miscarriages at 9, 7 and 8 weeks respectively. She has not had any difficulty falling pregnant.
- Discuss this woman’s chance of having a further miscarriage based on the information in the scenario
- Three consecutive miscarriages increases risk of miscarriage (40%)
- However, still has 75% chance of livebirth in the next 5 years
- Age is 38 years and over 35 years, risk of miscarriage increases
- Would recommend further investigations
- Justify screening this couple for: Antiphospholipid syndrome (APS)
- Has had 3 consecutive miscarriages which fits criteria of recurrent miscarriage therefore suitable for screening for APS
- 15% of women with recurrent miscarriage carry antibodies for APS
- Part of criteria is early trimester losses and positive for Ab – either anti cardiolipin or lupus anticoagulant on 2 separate occasions 12 weeks apart
- Treatable cause of miscarriage so can potentially treat in this couple and reduce chance of loss
- Describe how the diagnosis of antiphospholipid syndrome would change your management of her next pregnancy beyond routine care
- Evidence has shown that if there is APLS (with anti cardiolipin or lupus anticoagulant positive), would recommend commencing aspirin and UF heparin in 1st trimester as this leads to less likelihood of miscarriage and more likely to have successful livebirth
- Counsel about increased risk of VTE – avoid situations of prolonged immobility
- Would book IOL and cease heparin 24hrs prior to IOL
- Cease aspirin 36wks
- Growth US not required
- Dr’s clinic during pregnancy
- Increased risk of PET
- Increased risk of congenital heart block
- Active management 3rd stage due to risk of PPH
Feb 2012 - Question 12
A 24 year old woman presents at 8 weeks of amenorrhoea with a scan that concludes she has a missed miscarriage / early pregnancy loss.
a. In Australia and New Zealand, what transvaginal ultrasound criteria are used to diagnose “missed miscarriage” / “early pregnancy loss”? (3 marks)
- Mean gestational sac diameter >= 25mm with yolk sac or fetal pole
- OR crown rump length >=7mm with no cardiac activity
- OR ultrasound after gestational sac with fetal pole but no yolk sac – 11 days later
- OR ultrasound after gestational sac with no fetal pole and no yolk sac – 14 days later
She has an empty intrauterine gestation sac measuring 30mm. You are asked to counsel her with respect to her management options.
b. List three management options available for this woman, their respective success rates and rank the effectiveness of each option with respect to success of treatment for missed miscarriage / early pregnancy loss. A table may be used. (6 marks)
TreatmentSuccess ratesIssuesExpectant70-80%
Least invasive but also least successful
Increased risk of unplanned admission and requiring D&C
Bleeding/pain
Need to live near ED
Need to follow up in 2 weeks with repeat US / bHCG
Unpredictable – may not work
Avoids surgery
Medical80-90%
Increased risk of unplanned admission and requiring D&C
Bleeding/pain/nausea+vomiting
Need to live near ED
Need to follow up in 2 weeks with repeat US / bHCG
Avoids surgery
Surgical95-97%
Surgical risks – uterine perforation, Asherman’s
Anaesthetic risks
Small risk repeat curette
No follow up needed
c. The randomised controlled Miscarriage Treatment Trial (MIST trial BMJ 2006) examined the risk of harm for each management option. Choose three outcome measures from this trial and outline the result obtained. (6 marks)
Outcome measuresResult Infection within 14days - documentedNo increased risk of infection with expectant or medical or surgical within 14 days of interventionUnplanned admissionIncreased risk of unplanned admission for expectant and medical compared to surgicalSurgeryIncreased risk of surgery for expectant and medicalAnxiety/depressionNo difference in anxiety/depression scoresAnalgesiaMore analgesia in expectant management compared to medical and surgical
2013 July SAQ
Question 9 – Recurrent miscarriage
A 32 year old woman presents with a history of three miscarriages (G3P0) within the last 2 years at 8, 9 and 8 weeks gestation respectively. No investigations have been performed. You are seeing her and her partner to discuss their management.
- Describe and evaluate the four recommended investigations which may establish a cause for their recurrent miscarriage prior to another pregnancy. (8 marks)
- APLS screen
- Pelvic ultrasound – congenital anomalies
- Karyoptype – balanced translocations
- Thrombophillia screen – factor V leidein, prothrombin mutation, protein S
- Heparin can help with T2 miscarriage and improve livebirth rate but not recurrent T1
- Anti-phospholipid antibody screen (anti-beta-2 glycoprotein, anti-cardiolipin antibody, lupus anti-coagulant
- presence increases rate of miscarriage
- may benefit from treatment with aspirin + heparin once conception confirmed (RCOG, B)
- All women with recurrent T1 miscarriage and all women with 1 or more T2 miscarriage should be screened before pregnancy for APL Ab (RCOG, D)
- Two positive tests at least 12 weeks apart
- APL Ab in 15% of women with recurrent miscarriage
- ? mechanism
- Inhibition of trophoblastic function and differentiation
- Activation of complement pathways at materno-fetal interface local inflammatory response
- Thrombosis of uteroplacental vasculature later in pregnancy
- Cytogenic analysis on POC of the third and subsequent consecutive miscarriages (RCOG, D)
- If karyotype of the miscarried pregnancy is abnormal, there is a better prognosis for next pregnancy
- Risk of miscarriage as a result of fetal aneuploidy decreases with an increasing number of pregnancy losses
- Maternal and paternal karyotype where POC reveals an unbalanced structural chromosomal abnormality (RCOG, D)
- If balanced translocation, chance of having a healthy child is 83%
- Only 0.8% of couples will have a pregnancy with an unbalanced translocation (hence target parental karyotyping to those with abnormal karyotype found in POC)
- NB: chance of having a healthy live birth is 50 – 70% which is higher than that achieved with PGD + IVF (~30%)
- One partner carries a balanced structural chromosomal anomaly (balanced reciprocal, Robertsonian translocation) in 2-5% of couples with recurrent miscarriage
- Thrombophilia screen (FVL (APC resistance; including heterozygous), prothrombin mutation, Protein S deficiency – if T2 miscarriage (RCOG, D)
- Strong association with T2 miscarriage found between those three inherited thrombophilias
- Heparin therapy during pregnancy may improve the live birth rate of women with a T2 miscarriage associated with inherited thrombophilias (RCOG, A)
- Insufficient evidence to evaluate the effect of heparin in pregnancy to prevent a miscarriage in women with recurrent T1 loss associated with inherited thrombophilia (RCOG, C)
- Pelvic USS to assess for uterine anomalies +/- hysteroscopy, laparoscopy or 3D pelvic USS (RCOG)
- role of uterine anomalies in recurrent miscarriage is debatable
- ? septate uteri more likely to miscarry in first trimester; arcuate uteri miscarry more in second trimester
- PCOS linked to increased risk of miscarriage - ? secondary to insulin resistance
- TSH, T4 untreated hypothyroidism associated with recurrent miscarriage – identification and treatment of hypothyroidism may prevent future miscarriage
- HbA1c: high HbA1c linked to recurrent miscarriage
- Well controlled DM is not a risk factor for miscarriage
History, examination & investigation did not determine a cause for their previous miscarriages. You are seeing the woman for a follow‐up consultation.
- Outline and justify four issues which are relevant to her next pregnancy. (4 marks)
- Send off POC if further miscarriage occurs
- Lifestyle – cease smoking, EtOH, weight loss
- Discuss option of IVF for recurrent miscarriage
- Provision of support and reassurance during early pregnancy
- Women with unexplained recurrent miscarriage have an excellent prognosis for future pregnancy outcome without pharmacological intervention if offered supportive care alone in the setting ofa dedicated early pregnancy assessment unit (RCOG, B)
- ~75% successful pregnancy
- Regarding pharmacological intervention for prevention of recurrent miscarriage
- Evidence does not support the empirical use of heparin +/- aspirin in idiopathic recurrent miscarriage so its use should be resisted
- RCT (PROMISE) identified that progesterone treatment compared to placebo did not effect the rate of miscarriage
- insufficient evidence to evaluate the effect of metformin in pregnancy to prevent miscarriage (no RCT evidence; only evidence from uncontrolled small studies)
- Provision of routine antenatal care including completion of antenatal serology screening, early dating USS, aneuploidy screening
- Regarding use of IVF + PGD – chance of successful pregnancy higher if attempt natural conception, compared to conception through IVF + PGD
Two randomized controlled trials (RCTs) of treatment using heparin and low‐dose aspirin for unexplained recurrent miscarriage provide Level 1 evidence for pharmacological intervention.
c. With respect to one of these RCTs
i) Name the trial or its lead author. (1 mark)
ii) State the main conclusion of the trial. (1 mark)
iii) Identify one important weakness in the trial design. (1 mark)
Clark et al. Blood 2010; 115; 4162‐7
- SPIN (Scottish Pregnancy Intervention) Study: a multicentre, randomized controlled trial of LMWH and low dose aspirin in women with recurrent miscarriage
- Use of LMWH and aspirin in women with 2 or more consecutive previous pregnancy losses, with no evidence of anatomic, endocrine, chromosomal or immunologic abnormality, does not reduce pregnancy loss rate
- Trial not specifically investigate women in particular subgroups which may have different natural prognoses
- women with 3 or more pregnancy losses
- also included women who had had a previous successful pregnancy
- in women with a particular heritable thrombophilia
Kandor et al. NEJM 2010; 362: 1586‐96
- ALIFE (Anticoagulants for Living Fetuses) – Aspirin plus Heparin or Aspirin alone in women with recurrent miscarriage
- Use of aspirin alone, or aspirin plus LMWH, in women who have had two or more unexplained miscarriage does not increase the rate of live birth
- Complete follow up data not available on all enrolled women due to premature cessation of the trial (completion considered futile as no difference observed).
Rate of study drug adherence only 85% which could have increased the statistical uncertainty around the observed absence of effect.
Broad definition of ‘recurrent miscarriage’ was used (ie: 2 or more).
Study underpowered to investigate sub-groups of women (eg: with inherited thrombophilia).
2015 July SAQ and July 2014
Question 11 - Ectopic pregnancy
A 20 year old primigravid woman presents to the early pregnancy assessment unit at 7 weeks amenorrhoea with a history of vaginal spotting over the last few days. A diagnosis of tubal pregnancy is made on the basis of a transvaginal scan which shows an empty uterus with a 2.5cm left adnexal mass with no visible heartbeat. There is a corpus luteum seen in the left ovary. Her serum quantitative hCG is 2000IU/L at presentation.
- What specific piece of information included in the scenario above informs you that expectant management is contraindicated in this woman? (1 mark)
- Symptomatic with vaginal spotting
- bHCG>1500
-
Identify the clinical criteria to be fulfilled before considering medical management of ectopic pregnancy.
- No pain
- Haemodynamically stable
- Mass <3.5cm
- No signs of rupture on US – no free fluid, haemoperitoneum
- No IUP on US
- No heartbeat
- bHCG<5000
- Lives close to emergency department
- Will follow up on day 4 and 7 for bHCG
- Normal LFT and UEC
- No contraindications to methotrexate – abnormal renal function, allergy
i) Identify the clinical criteria for which information has been provided in the scenario above. (3 marks)
ii) Identify the additional information that needs to be obtained before medical management should proceed. (2 marks)
1. Assuming she has no clinical contraindications, outline your approach to medical treatment for this patient. (6 marks) - Ensuring all of above criteria are fulfilled then needs to be counselled about methotrexate
- Single dose based on height and weight given day 1 - 50mg/m2 and administer IM
- Need FBC, UEC and LFT baseline bloods to ensure no abnormal function
- Need bHCG on day 4 and day 7 to ensure it is reducing
- If increased day 1 to day 4, that is normal
- But need >=15% reduction between day 4 and day 7
- If not reducing, may need second dose day 7 and check again day 4 and 7 after second dose
- If reducing, need bHCG weekly until negative
- Success rate
- bHCG < 1000 98%, 1000 – 5000 95%, 5000 – 10,000 86%
- Risk of tubal rupture still present (7%) so risk of surgery still present
- During this period:
- Avoid folate supplements or folate containing food
- Need contraception to avoid new pregnancy
- If any severe pain or bleeding, present to ED
- If bHCG rising, may need another US to exclude heterotopic
- Risks of methotrexate
- Nausea/vomiting/GI upset
- Deranged LFTs
- Stomatitis
- Normal to have some pain as ectopic is resolving
- Medical treatment does not affect fertility
- If included in recurrent miscarriage (3 consecutive miscarriages), then consider referral to recurrent miscarriage clinic
- Test for STI (chlamydia/gonorrhoea) if high risk – risk of PID
- No pregnancy for 3 months
- Anti D if rhesus negative
- Increased risk of ectopic in future pregnancies 15%
- Need early US next pregnancy to confirm location
- CST
- Support and social work
- With respect to treating ectopic pregnancy in general, list two (2) surgical options available and the indication for each option. (2 marks)
- Salpingectomy
- Remove fallopian tube
- Indication: normal contralateral fallopian tube, bHCG>5000, failed medical management, live ectopic, suspected tubal rupture, less likely to have retained trophoblastic tissue compared to salpingostomy
- Salpingostomy
- Remove products from fallopian tube
- Indication: abnormal contralateral fallopian tube, to preserve fertility
July 2019
Caesarean scar ectopic
A 29 year old G2P1 present with early pregnancy bleeding, no associated pain or other symptoms. She is referred for a transvaginal ultrasound.
- Justify the request for this investigation (2 marks)
- TV US to confirm:
- Viable pregnancy – has heartbeat
- Location – is not extrauterine pregnancy
The ultrasound shows features of a caesarean scar ectopic.
- What are the differentials for a csep? (2 marks)
- Lower segment fibroid
- Placenta accreta
- Cervical ectopic
- Lowly implanted IUP
- Caesarean scar defect in uterine wall - ithmocele
- What are the diagnostic features on ultrasound of a csep? (3 marks)
- Gestational sac within caesarean section scar tissue
- Gestational sac invading thin part of myometrium <3mm and into bladder, defect
- Increased blood flow to the area
- Empty endocervical canal
- No intrauterine pregnancy
- Evaluate the management of csep and rate most recommended to least recommended treatment options (6 marks)
- Assess for haemodynamic instability
- Anti D if Rhesus negative
- Counsel unlikely viable pregnancy and can be dangerous if ruptured
- Most recommended is surgery, then medical management with methotrexate then least recommended is conservative
- Surgery
- Hysteroscopic resection
- D&C
- Laparotomy and wedge resection – remove scar and reapproximate uterus, open/TV/lap
- Recommended due to risk of uterine rupture, ectopic rupture and bleeding
- Medical with methotrexate
- Can give IM methotrexate systemically or inject methotrexate into gestational sac to reduce size or to remove ectopic
- This can also reduce size of ectopic
- Recommended if larger size, if live ectopic, if surgical risk too high
- Risk of rupture, bleeding, failure
- Conservative
- Wait for spontaneous resolution of ectopic
- Only for very small gestational sac, not alive, can monitor
- Not recommended due to high risk of uterine rupture, bleeding and haemodynamic instability
2016 January SAQ
Question 12 - Medical management of miscarriage and early TOP
- Discuss the pharmacology of mifepristone and misoprostol that enables them to act synergistically to achieve a medical termination of pregnancy. (4 marks)
- Mifepristone: progesterone antagonist, binds to progesterone receptors to prevent endogenous progesterone acting so cannot maintain pregnancy, sensitises uterus to prostaglandins
- Misoprostol: prostaglandin analogue that causes uterine contractions to expel products by binding to smooth muscle to uterine wall, causes cervical effacement and softening, degrades collagen
The Management of miscarriage: expectant, medical or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial) Trinder J. et al 2009 is a RANZCOG Landmark Trial.
b. With respect to the MIST Trial:
i) Outline the intervention in each of the three (3) arms of the trial. (3 marks)
- Conservative/expectant – no intervention
- Medical
Incomplete miscarriage – misoprostol 800 microg PV
Early fetal demise – mifepristone 200mg po, then misoprostol 800 microg PV 24-48hrs later
D&C offered if expulsion of RPOC had not started within 8 hours of misoprostol administration
- Surgical with D&C
ii) State the result of the primary outcome measure. (1 mark)
- No difference in infection rates at 14days (2-3%)
- Increased unplanned admissions for expectant and medical
- Increased D&C for expectant and medical
iii) Outline two (2) statistically significant advantages of surgical management for early fetal demise. (2 marks)
- Reduced risk of unplanned admission
- Reduced risk of requiring a second procedure
- Reduced analgesia requirements compared to expectant
- Cessation of bleeding earlier in surgical than medical or expectant although no Hb difference
You are seeing a 23 year old woman at 10 weeks gestation with an incomplete miscarriage on ultrasound scan. She is having minimal bleeding. After discussion of her options her preference is to go home without any intervention. She is provided with the contact details of her closest hospital Emergency Department prior to leaving the Early Pregnancy Assessment Unit.
- Discuss the information you give her regarding expectant management in this situation with reference to the results and discussion from the MIST trial (see above). (5 marks)
- Expectant management safe option for miscarriage management if haemodynamically stable, close to ED, able to come for follow up
- 70-80% success rate
- Increased risk of unplanned admission and requiring an emergency D&C
- Increased analgesic requirements
- Risk of heavy bleeding requiring emergency surgery
- Risk of failure – 20-30% failure rate requiring medical management or surgery
- No increased risk of infection compared to medical or surgical
- No difference in anxiety or depression scores 6-8 weeks post miscarriage
Endometriosis
Definition = endometrial glands and stroma outside uterine cavity; 11.4% in australia
Risk factors:
- Nulliparous
- Early menarche, late menopause
- HMB
- Short cycles
- FHx
Pathogenesis:
- Theory of retrograde menstruation - endometrial cells flow backwards through fallopian tubes and into peritoneal cavity during menses
Common sites:
- Ovaries and ovarian fossa
- Uterosacral ligament
- POD
- Bladder
Ex:
- Tender on VE, nodules in posterior fornix
- Adnexal mass
- Immobility of cervix/uterus
Ix:
- Normal US
- Endometrioma - avascular, thick walled cyst, ground-glass appearance, uni or multilocular, smooth septations, no solid components
- Increased Ca125 - not done for diagnosis as it can be elevated in other conditions, done if ovarian cyst appears malignant
- AMH
- DIE scan
- Pelvic MRI - not to diagnose but to assess extent of deep endo
Management - symptom focused:
- NSAIDs - avoid COX2 inhibitors (can delay ovulation)
- COCP - oestrogen suppresses ovarian function and reduces endometriosis disease activity and pain
- POP
- IUD or implanon
- Depot - but reduces bone density long term
- GnRH analogue - initial increase of gonadotrophins then decrease, menopause SE due to downregulation of HPA axis, only for 6months due to risk of bone loss, can be 12 months with hormonal add-back (prog only or oes/prog) which prevents bone loss and hypoestrogenic symptoms; can be adjunct before surgery for severe disease
- GnRH antagonist - menopause SE
- Danazol - inhibits LH surge and increases androgen; causes androgenic SE
- Aromatase inhibitors - inhibit conversion of androgens to oestrogen
- Neuropathic meds - but no evidence
- Surgery - for refractive pain, severe symptoms, fertility; to excise tissue (preferred over ablation), remove endometriomas (>5cm) and adhesiolysis - still requires postop medical suppressive therapy to prevent recurrence
- Remove endometrioma - improves spontaneous pregnancy rates, not been shown to improve IVF; risk of reducing ovarian reserve
- Hysteroscopy +/- BSO - only if completed family, refractory symptoms that failed other treatments; can still have HRT; need to be aware of risks of surgical menopause
- Non-pharmacological - diet, exercise, CBT
No evidence for Chinese herbal medicine or acupuncture
ASRM Staging:
- 1: minimal disease, no significant adhesions
- 2: <5cm implants on peritoneum and ovaries, no significant adhesions
- 3: moderate disease, peritubal or periovarian adhesions
- 4: severe disease, multiple superficial and deep implants, large ovarian endometriomas, filmy and dense adhesions, dense adhesions of tube or ovary, obliterated pouch of Douglas, DIE lesions >3cm, loss of normal tube/ovary anatomy
Complications:
- Dysmenorrhoea
- Dyspareunia
- Dyschezia
- HMB
- Chronic pain
- Infertility - from anatomic distortion, endometriomas, inflammation; can be referred for ART after 6months (instead of usual 12); also look for other causes of infertility
- Bowel/bladder dysfunction
- Anxiety/depression
- Fatigue
- Endometrioma
- Pregnancy - preterm birth, PET, CS, praevia, low birth weight, miscarriage - no additional surveillance advised
- Epithelial ovarian cancer (low overall risk) - actually no evidence that endometriosis causes cancer
- Atherosclerosis
- DIE (deeply infiltrating endometriosis) - endometriosis >5mm deep into peritoneum; includes retrovaginal septum, rectum, bladder, ureter, rectosigmoid colon
Treatment of infertility:
- 6 months natural conception and <35yrs
- If >35yrs with stage 1 or 2 endo OR stage 3 or 4 endo, can proceed directly to ART
- Stage 1 or 2 does not impact ART outcomes but stage 3 or 4 can
- Ovulation induction + IUI- clomiphene or letrozole
- OI + IUI - enhances follicular development, ovulation and luteal progesterone levels and places sperm high in reproductive tract
- IVF
- Surgical excision of endo - improves pregnancy rates in mild to mod
- If stage 3-4 endo, OI not helpful, can do surgery but only once - repeat surgery does not improve fertility (only reduces pain)
- Oophorectomy not recommended as loses ovarian tissue
- Recurrence of endometrioma (25%)
Monitoring cyst:
- If not removing, US every 6months for 1-2yrs
- Operate if onset of new symptoms or increase cyst size >5cm or volume or appears complex
- Hormone therapy does not treat cyst but can be used after removal to prevent recurrence
National action plan for endometriosis:
- Targets education and awareness, clinical care and research
- Need prompt diagnosis and early treatment
- Need emotional support and support groups
- Need comprehensive multidisciplinary care
- Refer to Gynae for deep endo on US, severe symptoms, not responding to initial treatment, suspect endo
Resources:
- Uptodate
- NICE guidelines
Adenomyosis
Definition:
- Endometrium in the myometrial layer causing hypertrophy and hyperplasia of myometrium
- In women of reproductive age, usually resolves after menopause
- Usually diagnosed post hysterectomy
Types:
- Diffuse – uniformly enlarged and boggy
- Focal - small areas, can resemble fibroid
Risk factors:
- Parity
- Older age
- Also has endometriosis or fibroids
- Early menarche
- Shorter menstrual cycles
- Hx of dysmenorrhoea or pelvic pain
Symptoms:
- Pelvic pain
- Dysmenorrhoea
- Dyspareunia
- Heavy menstrual bleeding
- Usually no dyspareunia
Ex:
- Mobile, diffusely enlarged (globular), soft (boggy) uterus
- Adenomyomas (look like fibroids
- Tender uterus
- Uterus may be fixed but this is from endometriosis
Ix:
- bHCG - rule out pregnancy
- TV US - first line
- MRI - usually if planning conservative treatment, to look for diffuse or focal adenomyosis
- In both, look for asymmetrical thickened, loss of endometrium-myometrium border, myometral cysts, increased myometrial heterogeneity
- Endometrial biopsy - cannot diagnose adenomyosis but to look for other causes of AUB
Management:
- Hormonal - COCP, POP, IUD*, implanon, depot
- Aromatase inhibitors
- GnRH antagonist
- Hysterectomy - definitely treatment, can retain ovaries
- Ablation for HMB - no evidence for adenomyosis
- Uterine artery embolisation - if completed family and CI to hysterectomy
- No evidence that excisions in surgery will help pain
- Removing adenomyomas difficult - no easy surgical plane like with fibroids; also risk uterine rupture in pregnancy
DDx:
- Pregnancy
- Endometrial polyps
- Endometrial cancer
- Uterine fibroids
- Uterine sarcoma
Chronic pelvic pain
Definition:
- Non cyclic pelvic pain >6months below umbilicus causing functional disability or requires treatment
- Affects 25% of reproductive aged women
- Chronic pelvic pain syndrome (no diagnosis other than chronic pain) likely have central sensitisation
- Aim of treatment is to regain function
Causes:
Gynae
- Endometriosis
- Adenomyosis
- Chronic PID
- Ovarian cysts
- Pelvic congestion syndrome
- Malignancy
- Intraabdominal adhesions
- Ovarian remnant syndrome
Urologic
- Bladder pain syndrome/interstitial cystitis
- Renal stones
- Urethral diverticulum
GI
- IBS / IBD / colitis
- Coeliac
- Chronic constipation
- Cancer
MSK
- Myofascial pelvic pain syndrome
Psychosocial
- Abuse
- Depression/anxiety/mood disorders
Opioid dependency
Hx:
- Exclude life-threatening cause first
- Gynae, obstetric, urinary, gastro, MSK, sexual and psychosocial Hx (abuse)
- Provoking factors
- Quality
- Radiation
- Setting - e.g. during menses
- Temporal/timing - e.g constant, cyclic
- Associated symptoms - sexual, urinary, bowel, autonomic symptoms, sleep
- Drug use
Ix:
- Pain diary
- Level of function
- bHCG
- Urine MCS
- STI screen
- TV US
- DIE scan or MRI (for adenomyosis)
- Diagnostic laparoscopy - if other treatments don’t work; may help develop woman’s beliefs about her pain
- Ca125 if concerned for malignancy
Mx:
- Multidisciplinary approach
NON-PHARMACOLOGIC
- Physiotherapy (for reproducible pain)
- CBT, mindfullness, exercise
- Neuromodulators
PHARMACOLOGIC
- Non opioid medications - NSAIDs, paracetamol
- Cyclic pain → hormonal treatment (COCP, POP, IUD, implanon)
- Neuropathic pain meds - gabapentin, pregabalin
- TCA
- SNRI
- Opioids (be cautious due to risk of addiction and SE, only for short term post op or bridge to surgery)
- Trigger point injections (with local)
- Surgery is last resort for chronic pain (may be required for acute depending on cause) - can be for severe DIE, to reverse a procedure; multiple surgeries does not improve pain
- Adhesiolysis - for dense adhesions only, not fine
Complications:
- Impaired QOL
- Urinary or bowel symptoms
- Anxiety/depression
- Stress
Resources:
- Uptodate
- RCOG
Fibroids
Pathogenesis:
- Non cancerous neoplasms arising from smooth muscle cells and fibroblasts
- Normal myocytes transform into abnormal myocytes
- Aromatase, oestrogen and progesterone upregulated in leimyomas
- Increased VEGF, TGF, GM-CSF
Classification:
- Subserosal
- Intramural - in muscle, can distort cavity
- Submucosal - protrude into cavity; FIGO classification (type 0 = completely within cavity; type 1 = extend <50% into myometrium; type 2 = extend >50% into myometrium)
- Cervical
Risk factors:
- Reproductive age
- Nulliparity
- Early menarche <10yrs
- Hormonal contraception - especially progesterone
- DES exposure
- High BMI
- Genetics
- Smoking/EtOH
- Pregnancy - become larger, risk of red degeneration
Symptoms:
- Asymptomatic
- HMB
- Bulk related (bloating, difficulty voiding/urinary retention, bowel issues, pelvic pressure, pain, dyspareunia)
- Reproductive (subfertility, miscarriage, obstetric complications
- Degeneration or torsion - presents with acute pain, low grade fever, increased WCC; self resolves
- Prolapsed fibroid (through cervix) - presents with pain, bleeding, infection
- Affects QOL
Ix:
- bHCG
- FBC/ferritin
- Pelvic US*
- Endometrial biopsy/hysteroscopy - for hyperplasia/cancer
- MRI - if required
- Saline infused hysterosonogram - characterise extent of protrusion into cavity
- Renal tract US - for urinary obstruction, hydronephrosis
Treatment:
EXPECTANT
- If asymptomatic, attempting pregnancy, small size, peri or postmenopausal, stable size
MEDICAL
- TXA, NSAIDs
- COCP
- IUD (difficult in distorted cavity)
- Progestin only (POP, implanon) - less effective
- GnRH agonist or antagonist - reduce fibroid volume (more agonist) and allow lap rather than open surgery, menopause SE, can reduce bone density, do with add-back (COCP, POP)
SURGICAL
- Uterine artery embolisation - shorter hospital stay, less pain but risk of readmission, post embolisation syndrome and may require hysterectomy anyway; only for premenopausal due to risk of mistakenly treating a uterine sarcoma; not fertility sparing; avoid if concerned for sarcoma; can require intracavity of retrieval after embolisation
→ Aim is to embolise particles in uterine artery until flow becomes sluggish → ischaemic injury to fibroids → necrosis and shrinkage of fibroid → however normal myometrium because it has collateral blood supply from vaginal and ovarian arteries
→ 80-90% asymptomatic at 1yr
→ Unknown effect on fertility – likely negatively impact and therefore not recommended if wanting to fall pregnant
- Endometrial ablation - effective but may not work and need contraception
- Hysteroscopic resection of submucosal fibroids (FIGO type 0 or 1) - risk of incomplete resection or uterine perforation; indicated for AUB, recurrent M/C or infertility; saline deficit max 2.5L; glycine deficit max 1L
- Myomectomy (lap or open) for subserosal or intramural - can inject vasopressin to prevent blood loss; risk of uterine rupture in pregnancy; for fertility sparing; wait 3-6months before pregnancy
- Vaginal myomectomy - for prolapsed fibroids through the cervix
- Hysterectomy - definitive treatment but surgical risks and recovery time, risk of prolapse
No evidence for aromatase inhibitors or SERM or mifepristone
UAE and GnRH agonist preferred for bulk symptoms
Complications:
- Poor QOL
- Anaemia
- Urinary retention
- Bowel dysfunction
- Infertility
- Sarcoma
Pregnancy complications:
- Recurrent miscarriage
- SGA
- Preterm birth
- Placenta praevia
- Obstructed labour
- Caesarean section
- Mapresentation
- Abruption
- Enlarged fibroid (especially if >5cm)
- Red degeneration or torsion in pregnancy
Hysteroscopic myomectomy complications:
- Pain
- Infection
- Fluid imbalance - hyponatraemia with glycine deficit >1L
- Uterine rupture if myomectomy performed - aim CS 37-38+6 (earlier at 36 if extensive myomectomy)
- Bleeding post myomectomy - can use vasopressin beforehand, foleys balloon, check for uterine perforation
- Intrauterine adhesions
- 20% recurrnence
Comparing UAE vs surgery (myomectomy and hysterectomy) for symptomatic fibroids:
- No difference in patient satisfaction at 2 and 5 years
- No difference in short and long term major complications
- UAE has reduced length of procedure and length of hospitalisation but increased short term minor complications, unplanned readmissions and surgical re-intervention
- UAE complications (immediate - groin haematoma, pseudo-aneurysm; early - embolisation syndrome, expulsion of necrotic fibroid, vaginal discharge; late - ovarian insufficiency, re-intervention)
Resources:
- Uptodate
- RANZCOG - Uterine Artery Embolisation for the Treatment of Uterine Fibroids and Fibroids in Infertility
Premenstrual syndrome
PMS (ACOG definition) = at least one symptom associated with “economic or social dysfunction” that occurs during the five days before the onset of menses and is present in at least three consecutive menstrual cycles
PMDD = premenstrual dysphoric disorder
Definition:
- PMS is group of symptoms before periods
- PMDD is when it is severe, disabling manifestation of PMS (affects work/school functioning); mood symptoms predominate
Pathogenesis:
- Thought to be due to cyclic changes in ovarian hormones
Symptoms:
- Fatigue
- Bloating
- Tired, angry, worried
- Mood swings
- Irritability
- Feeling sad, crying
- Eating more
- Difficulty sleeping or more sleeping
- Breast tenderness
- Headaches
- Affects functioning
- Symptoms resolve after menses (unlikely depression/anxiety)
Ix:
- Clinical diagnosis
- Record symptoms and check it in the second half of cycle (should be symptom free during follicular phase) → Daily Record of Severity of Problems (DRSP) form
- Rule out other causes - TSH, bhCG
Mx:
- Exercise
- Relaxation techniques/CBT
- Avoid salty foods and large meals
- NSAIDs
- Continuous COCP - ones with higher levels of drospirenone are more effective (Yaz)
- Can give SSRIs for PMDD - take for at least 2 cycles; can give continuous or cyclically in 2nd half of cycle; SE nausea, insomnia, reduction in libido
- Estradiol patches
- Micronised progesterone or IUD
- GnRH agonist with oes-prog add back therapy - only if other treatments don’t work; for 3months
- Hys/BSO if extremely severe as last resort (after GnRH of 6 months and is working but can’t be on it for >6months) and give HRT if <45yrs
- Multidisciplinary care - GP, gyn, psych, dietician
TCA, MAO-I, lithium and benzos not recommended
Resources:
- Uptodate
- RCOG
