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.
How to perform a myomectomy
Sign in
Pregnancy test
Allergies
Antibiotics
GA/regional
Position
Prep and drape
Time out
IDC
EUA
Bleeding management
Vasopressin (20 units in 100 mL saline used in aliquots of 30 mL every half hour PRN)
Tranexamic Acid
Blood available
Skin incision made with routine entry to the peritoneum.
Peritoneal cavity explored
Pack bowels
Retractor
Inject vasopressin
Incise over fibroid to identify capsule
Myomectomy screw/mother-in-law for traction
Visible blood supply interrupted with coagulation diathermy.
If breach, endometrium closed with continuous Vicryl.
The myometrial defect closed with interrupted Vicryl sutures and the serosal defect with a continuous locking Vicryl sutures.
Haemostasis is checked.
Adhesion barrier
Packs and retractors removed.
Abdomen closed.
Post-op
Remove IDC Day 1 post op
Mobilise
Drain
VTE prophylaxis
No heavy lifting/driving 6 weeks
Recommend Caesarean section for future deliveries
Follow-up
Return advice
Fibroids and infertility
Fibroid positioning appears to influence fertility therefore imaging such as MRI should be used to exclude uterine cavity involvement.
Subserosal - no significant effect
Intramural - reduced fertility and increase in miscarraige rate
Submucosal - reduced fertility and increased miscarriage rate.
Indications for myomectomy in infertile women:
- ART with submucosal fibroids
- Infertile women who are symptomatic with fibroids
Couples presenting after multiple failed cycles of ART where the female has intramural fibroids.
Fibroid and pregnancy
Fibroids and pregnancy: Prevalence 10% Associations or complications develop in 10-30% PPH needing hysterectomy or MROP Malpresentation Preterm labour C-section in labour Placental abruption Placenta preavia IUGR
Effect of pregnancy on fibroid:
Likely to increase in size in 1st trimester then remain stable or decrease in size
Most common complication is pain - more likely if fibroid is >5cm and during 2nd and 3rd trimesters related to red degeneration or torsion if pedunculated.
Care antenatally
Optimise Hb
Serial growth scans
Had myomectomy c-section
Type of transformation zone in colposcopy
Type 1 - whole TZ including upper limit is ectocervix
Type 2 - Upper limit of TZ partly or wholey visible in the canal
Type 3 - upper limit of TZ cannot be seen in the canal
Features on cervix suspicious for invasion
atypical vessels irregular surface exophytic lesion necrosis ulceration gross neoplasm
Von Willebrand Disease
Von Willebrand disease (vWD) is the most common bleeding disorder in the world. About 1 in 100 people have this condition and about 9 out of 10 of them have not been diagnosed.
People with vWD have no or very little of, or a problem with, vWF adhesion molecule and carrier for VII that helps blood to clot.
Acute phase protein influenced by thyroid, estrogen and blood type.
Treatment:
dDAVP (desmopressin) IV, SC (20mcg), nasally (300mcg) 8 - 24rly for 1 - 3 days
Replacement from human derived factor VIII, cryo
Antifibrinolytic - txa
Topical - surigcel/gelfoam soaked in thrombin
Factor VIIa - bypasses a need for factor VIII
Avoid aspirin and NSAIDs
Type 1: This is the most common form. People with Type 1 vWD have lower than normal levels of VWF. Most lead normal lives with no need for treatment. Symptoms are mild and can include regular nosebleeds, bruising and, in women, heavy periods. It is still possible for someone with Type 1 vWD to have serious bleeding, especially after trauma or surgery.
Type 2: In people with Type 2 vWD, the VWF protein does not work properly, causing lower than normal vWF activity. Symptoms are moderate and can include regular nosebleeds, bruising and, in women, heavy periods. Some rare sub-types are associated with more severe bleeding symptoms.
Type 3: This is the rarest and usually the most serious form of the condition. People with Type 3 vWD have very little or no vWF. Symptoms are more severe and can include internal bleeding into your muscles and joints, sometimes without obvious injury.
Types 1 and 2 vWD are usually inherited in what is known as a ‘dominant’ pattern. This means that a parent who has von Willebrand disease has a 1 in 2 (50%) chance of passing a von Willebrand disease gene on to each of his or her children.
Type 3 vWD is usually inherited in a ‘recessive’ pattern, where the child inherits the gene from both parents. Even if both parents have mild symptoms or no symptoms at all, their children may be severely affected.
Describe how you would avoid injuring the ureter.
· good visualisation
· haemostasis
· identify anatomical landmarks – be certain of location of ureter
· caution with diathermy
· ureter can be seen on the lateral pelvic sidewall through the peritoneum and followed, when it is not visible it should be identified retroperitoneally and followed down to the site of laparoscopic interest.
· Dissection and mobilisation of ureter may be necessary
· Visualisation of peristalsis confirms ureter
· (ureteral catheters)
(Identifying ureter retroperitoneally:
· at round ligament, open periotoneum lateral to ovarian vessels / IP ligament
· bluntly dissect ovary and its vessels medially to enter posterior retroperitoneal space / retract IP ligament medially to expose ureter at pelvic brim on medial leaf of broad ligament.
· ureter will be seen adhered loosely to medial broad ligament
· crosses over iliac artery at pelvic brim at bifurcation of iliac vessels)
pelvic ureter:
· ureters cross iliac vessels to enter pelvic brim
· run retroperitoneally along lateral pelvic wall, lie in connective tissue sheath attached to medial leaf of broad ligament
· at cardinal ligament uterine artery crosses above ureter
· ureteric canal, runs anteriorly and passes onto ant vaginal fornix and enters trigonal region of bladder
How Mirena works to reduce HMB
Contains 52mg LEVONORGESTREL which is slowly released over 5 years at an initial rate of 20mcg/24 hours.
Good contraceptive: 99.9% effective at preventing pregnancy
After a few months the MIRENA may reduce menstrual flow to little or nothing
(86% reduction in blood loss after 3 months and 97%
after 12 months)
Effective treatment for uterine fibroids
Protective for endometrium
Effective treatment for severe dysmenorrhea
Manage HMB
Management options: medical treatment (PROVERA/ NORETHISTERONE/TRANEXAMIC ACID), endometrial ablation, MIRENA IUS (give pamphlet),
surgery
TAH, TLH (assessment of descent VH). Conserve ovaries but bilateral salpingectomies
Treating Hirsuitism
cosmetic measures, as well as hormonal, as it will take at least 6 months for hormone treatment to be effective
o Cosmetic measures: shaving, depilatory creams, electroysis
o Hormonal treatment: OCP with an antiandrogen (Yasmin or Diane 35) +/- antiandrogen such
as aldactone
The OCP will have added benefit of regulating the menstrual cycle
Tamoxifen and endometrium
Can cause benign cystic hyperplasia
Increase in endometrial polyps
An increased risk of endometrial adenocarcinoma in postmenopausal women 1.6% at 5 years and 3.1% at 5-14 years.
Any post menopausal women who has bleeding on Tamoxifen should have bleeding investigated.
Tamoxifen may increase the risk of congenital abnormalities a month washout period is advised before attempting conception
Diethylstilboestral
Synthetic oestrogen prescribed 1940-1980 to reduce pregnancy complications. Women who took it are at an increased risk of breast cancer. 1.25 x the general population and should have regular breast screening.
Daughters exposed to DES increased breast cancer, vaginal and cervical clear cell carcinoma and higher rates of uterine anomalies. Offer annual cytology screening and colposcopic examination of cervix and vagina. Begin screening at any time and continue indefinitely.
Sons exposed to DES increased risk of testicular abnormalities but not cancer or fertility problems.
Endometriosis
An inflammatory disease characterised by lesions of endometrial tissue outside of uterus
Dysmenorrhea, dysparunia and dyschezia
Surgical management consider if:
- Symptoms not responding to medical treatment
- Sure diagnosis of complex cysts- Significant pain and infertility
Surgery has been shown to reduce pain but laparoscopy and medical therapy for at least 18-24 months is superior prolonging times between surgery and improving fertility long term.
Recurrence 20% at 2 years and 40% at 5 years
Medical management:
NSAIDs
Neuromodulators e.g. Amitriptyline or Gabapentin
Ovulation suppression Depo-provera, COCP levlen or Yasmin or Mirena
Complex pain clinic
Pyschological support e.g. mindfulness pain diary
Pelvic floor physio
Education and pelvic pain foundation Australia resources.
Infertility with suspected endometriosis
Measure AMH
Assess fallopian tubes - hystosalpingogram
Father’s semen analysis
If she is AMA or one of above is abnormal schedule ART
Laparoscopy should be considered for patients in pain, cystectomy or histological diagnosis
Adverse effects of surgery e.g. diminishing ovarian reserve should be taken into account
Patients who fail to concieve spontaneously for 6-12 months should get ART.
