General Gynae Flashcards
Blood tests to differentiate between PCOS, CAH, Androgen producing tumours
PCOS: Testosterone increased, DHEAS normal, Cortisol normal, 17-OH-progesterone normal
Congenital Adrenal hyperplasia: Testosterone increased or normal, DHEAS increased, Cortisol normal or decreased, 17-OH-progesterone increased.
Androgen producing tumour – adrenal: Testosterone increased, DHEAS increased, Cortisol increased, 17-OH-progesterone normal
Androgen producing tumour – ovarian: Testosterone increased, DHEAS normal, Cortisol normal, 17-OH-progesterone normal
Palmer’s Point entry
- WHO sign in
- Allergy check
- Pregnancy test
- Antibiotics – nil, cefazolin if any incisions into peritoneum made
- General anaesthesia
- Orogastric tube
- WHO time out
- Lloyd Davis position.
- Clean and drape vaginally and abdominally.
- IDC
- EUA
- Manipulator
- Level out table
- Exclude splenomegaly
- Palmer’s point: midclavicular line, 2 cm below rib.
- Infiltration of skin
- Incise skin
- Veress needle perpendicular to floor
- 3 pops (Anterior sheath, posterior sheath, peritoneum)
- Attach syringe and aspirate looking for gastric/faceal material or blood.
- Saline drop test or gas test.
- Connect gas on low flow and start insufflating. Increase to high flow if initial pressure if less than 8mmHg. Insufflate until 20mmHg. Observe for symmetric distension of abdomen and liver dullness.
Salpingectomy for ectopic
• Insert camera. 360 degree sweep of entry site. Photos of upper abdomen. • 2nd port inserted under direct vision either suprapubically or in iliac fossa (identify inferior epigastric). • Reverse Trendelenburg. • Pressures down to 15mmHg. • Blunt graspers to tuck bowel over pelvic brim and expose pelvis. • Systematic examination of anterior pelvis, uterus, tubes, ovaries, ovarian fossae and pelvic sidewall, uterosacral ligaments, rectovaginal pouch and appendix. • Photos of all structures. • Check other tube • Do salpingectomy with LigaSure • Remove ports under direct vision. • Release gas from port. • Close sheath at any ports over 10mm. • Close skin. • Apply dressings. • Removal vaginal instruments. • TROC Post op: • Home same day with simple analgesia • Return advice • Review in 6 weeks with histology • 2 weeks off work with no heavy lifting
Vascular Injury
• Emergency • Inform team/SMO • Prepare for laparotomy • Call vascular surgeon • MTP • Fluids • Midline laparotomy • Compress vessel • Aortic pressure Post-op: o Location post op: HDU/ICU vs normal ward o Document o Debrief o VTE prophylaxis o Follow-up o Drains o IDC
Didelphys Uterus
Explanation
Effect on fertility
Late pregnancy complications
Failure of fusion of 2 paired Mullerian ducts around 12/40, duplication usually limited to uterus and cervix, with normal Fallopian tubes and cervix
15-20% have ipsilateral anomalies (obstructed hemivagina, renal agenesis)
- All women should undergo radiological renal investigation (IV pyelogram or renal USS)
75% of women have a septated vagina –> difficulties with intercourse
Advice for fertility:
o The anomaly does not affect the ability to conceive, fecundity as per general population, IVF rates not affected
o Spontaneous miscarriage 32%, RPL
o Potential for concurrent pregnancy in each womb
Late pregnancy complications: Risks: PTB (28%), PPROM, IUGR, malpresentation, obstructed labour, CS, PPH o Additional pregnancy care: High risk clinic/MFM Signs/sx of PTB to look out for Serial growth scans monthly from 24/40 Aim for NVD, CS for usual indications Optimise Hb antenatally, deliver in hospital IVL, G&H, active 3rd stage
Rectus Sheath Dehiscence
SURGICAL EMERGENCY
Pre-op care:
• Consent and arrange for immediate repair in OT – advise senior obstetrics, anaesthetics, general surgeons
• Consent - non-closure, bowel resection and stoma formation as well as usual risks e.g. pain, bleeding etc
• NBM, IV access FBC, G&H and fluids
• Broad spectrum IV antibiotics – Cef & Met
• Place moist dressing over the wound/bowel to prevent from drying out whilst awaiting theatre
Intra-op care:
• Open wound fully – edges may require debridement
• Take wound swab for MC&S
• Systematically inspect bowel for injury and viability
• May require resection +/- stoma formation
• Primary closure preferred if tissues healthy, but may require VAC dressing and delayed secondary closure if significant infection/necrosis present and suboptimal debridement
Post-op care:
• Continued antibiotic cover, chase microbiology
• Re-introduce diet as tolerated & vigilance for ileus
• Thromboprophylaxis
• Debrief with patient and family
• Involve wound care nurse
• ACC paperwork for treatment injury
• See in 6 weeks for follow-up or sooner if concerns
PCOS explanation and risks
PCOS (An endocrine disorder involving abnormal ovarian androgen production, increased insulin resistance and impaired oestrogen feedback – you meet the criteria for diagnosis with irregular menstruation, biochemical and clinical hyperandrogenism, and polycystic ovaries on your ultrasound)
Short term implications include difficult weight management, infertility, acne/hirsutism, and depression
Long term implications include CVD, diabetes, obstetric complications and malignancy/hyperplasia involving the endometrium
Hysteroscopy D&C
General anaesthesia, dilate cervix and view interior uterus after inflating with saline, using a hysteroscope, photos taken after viewing ostia
Curette used to sample endometrium
Risks eg VTE, bleeding, infection, damage to surrounding structures including perforation and cervical damage, and failure/need for further surgery
Differentials for vulval itch
Candidiasis
Lichen planus
Lichen sclerosus
Vulval psoriasis
EczemaFeatures to expect lichen sclerosis
- Affects the figure-of-eight area around the vaginal introitus and anal region
- Hyperkeratosis and pearly white lesions
- Often bilateral and symmetrical lesions
- Erosions
- Shrinkage of introitus
- Loss or fusion of labia minora
- Burying of clitoral hood and loss of vulval architecture
- Vagina and cervix not involved
Treatment of lichen sclerosis
Topical Steroids. Need to start with ultra-potent steroid (clobetasone proprionate 0.5%) for treatment then less potent (hydrocortisone 1%) for maintenance. No evidence for optimal regime. A common regime is potent steriod nocte for 4 weeks followed by alternative nights for 4 weeks then twice weekly for 4 weeks then review
Lichen Planus
Extra-genital involvement which is common with lichen planus e.g. mouth, eyelid.
Often present with pain instead of pruritis
Lichen planus can affect the Vagina.
Lesions are usually erosive, raw and red.
Irregular saw tooth acanthosis and increased granular layer and band like lymphocytic infiltrate seen in LP.
Lichenified dermatitis
Often associated with history of atopy e.g. eczema or psoriasis
History of itch and scratch cycle is typically longer than 12 months
Often have fissures at the natural skin fold. Not at posterior fourchette.
Chronic dermatitis with hyperkeratosis is the normal histology.
Lichen sclerosis
The labia minora are absent and there is a thickened white area at the posterior introitus. Speculum examination shows that the vagina is normal. Epidermis is atrophic with hydropic degeneration of basal cells and an homogenous pale zone in the upper dermis. There is a lichenoid infiltrate of mainly mononuclear cells in the dermis.
About 4% of women with lichen sclerosus develop vulvar cancer.
Fibroid treatment
Medical:
- COCP, PO progesterone cyclical or continuous, Mirena (increased risk of expulsion with large cavity)
- Tranexamic acid (on first day of bleeding to reduce volume of loss)
- NSAID for pain
- GnRH analogue such as Zolidex (Can reduce size of fibroid by 36% and improvement of symptoms after 12 weeks.)
Surgical:
- hysteroscopic submucous myomectomy: suitable if submucous fibroids <5 cm are identified
- Myomectomy: may be inappropriate in this perimenopausal age group as multiple fibroids, enlarged uterus and may be considered on basis of improving HMB and pain symptoms alone, and woman wishing to keep uterus and prepared to accept: increased surgical risks and morbidity of open abdominal myomectomy compared to hysterectomy; risk of re-treatment due to fibroid re-growth.
- Hysterectomy: Major procedure due to weight would carry more risks. 4-6 weeks off work afterwards.
Radiological:
- Uterine artery embolization: Placement of an angiographic catheter into uterine arteries via common femoral artery injection of embolic particles until the flow becomes sluggish in both uterine arteries. Aims to reduce uterine blood flow by producing ischaemic injury causing necrosis and shrinking. 65% of women avoid hysterectomy. Possible complications: groin haematoma, arterial thrombosis. Vaginal discharge, infection, expulsion of necrotic fibroid and VTE. Embolisation syndrome - fever nausea pain and malaise.
- MRI-guided focused ultrasonography: High frequency USS waves produce heat to denature proteins leading to cell death and shrinkage of fibroids. Quick recovery and very low morbidity.
