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MRCOG Part 2 > General Gynae > Flashcards

General Gynae Flashcards

1
Q

Describe causes of hirsuitism

A

Idiopathic
PCOS (70-80%)
Androgen secreting tumours - will have elevated DHEA-S on bloods >5 (adrenal source)
Late onset CAH
Drugs (steroids, testosterone)

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2
Q

Who requires Endometriosis follow up?

A

According to NICE
• Deep endometriosis involving the bowel, bladder or ureter or
• 1 or more endometrioma that is larger than 3 cm.

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3
Q

Management of PMS

A

2 month of symptoms diary
Must be clearly linked to cycle
GnRH agonist sometimes used in practice if doubt

RCOG treatment algorithm:
First line
Exercise
Cognitive behavioural therapy (CBT)
Vitamin B6 - do not exceed 10mg/day (neuropathy)
Combined new generation pill (cyclically or continuous)
Continuous or luteal phase (day 15-28) low dose SSRI e.g. citalopram 10 mg

Second line
Estradiol patches (100 micrograms) + micronised progesterone (100-200 mg on day 17-28 orally or vaginally) or LNG-IUS 52 mg
Higher dose SSRI continuously or luteal phase e.g. citalopram 20-40 mg

Third line
GnRH analogues + add-back HRT (continuous combined oestrogen + progesterone) or Tibolone

Fourth line
Surgical treatment ± HRT

Drosperidone containing COCPs likely better than Desogestrel/Norethisterone due to antiandrogenic and antiminerlcorticoid
Continuous use or shorter pill free break 24-4

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4
Q

How much can GnRH shrink fibroids?

A

GnRH max dosing for 6 months
Sometimes used pre-myomectomy
Can shrink fibroids by upto 30%

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5
Q

What is the risk of perforation with coil insertion?

A

Background risk 0.2%
Increases x 6 if breast feeding

1 in 20 risk of expulsion

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6
Q

Describe diagnostic criteria for IBS

A

Incidence in UK in women is 10-15%

ROME III Criteria

Recurrent abdominal pain or discomfort at least 3 days a month in the last 3 months associated with two or more of the following:
Improvement with defecation
Onset associated with a change in frequency of stool
Onset associated with a change in appearance of stool.

The above criteria must be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

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7
Q

Failure rate of the POP

A

3 in 1000 per year

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8
Q

What is the management of IBS?

A

Dietary and lifestyle measures
1st line pharmacological intervention includes: antispasmodics, laxatives (if constipation prominent, avoid lactulose), linaclotide and antimotility agents (if diarrhoea prominent)
2nd line: tricyclic antidepressants
3rd line: SSRI
4th line: psychological intervention

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9
Q

What are rates of pregnancy following treatment for TOA?

A

Antibiotics alone - 5-15%
Antibiotics and surgical drainage 30-60%

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10
Q

What is the cell surface composition of …

Peripheral NK cells vs Uterine NK cells

A

Uterine
CD56BRIGHTC16-ve

Decidualisation, implantation and embryo recognition
uNK also express killer cell immunoglobulin-like receptors (KIRS)
Binding of HLA-G by the KIR2DL4 receptor triggers inflammatory and angiogenic cytokines

Peripheral
CD56DIMC16+ce

Recognition of foreign antigens

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11
Q

What is the incidence of chronic pelvic pain after treatment for PID?

A

12% after one episode
30% after two episodes
67% after three or more episodes

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12
Q

What are treatment options for unexplained sub fertility?

A

Conservative - 74% spontaneous conception rate in 12 months
NICE recommends IVF over IUI/ovarian stimulation

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13
Q

What is the incidence of premature ovarian failure?

A

Menopause before the age of 40
Requires 2 x FSH 6 weeks apart to diagnose
Do not use AMH to diagnose

Incidence 1%

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14
Q

What are the histological findings of lichen sclerosus?

A

Epidermal atrophy or thinning
Hydropic degeneration of the basal layer - sub-epidermal hyalinisation
Dermal inflammation

Deep inflammatory infiltrate

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15
Q

Can HRT be used as a contraceptive?

A

Cyclical HRT inhibits ovulation in 40% of women
Therefore need concurrent contraceptive (coil can act as both progesterone part and contraceptive)

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16
Q

How is PCOS diagnosed?

A

Rotterdam criteria (need 2 out of 3)
1. polycystic ovaries (either 12 or more follicles or increased ovarian volume [> 10 cm3])
2. oligo-ovulation or anovulation
3. clinical and/or biochemical signs of hyperandrogenism.

Recommended biochemical test for hyperandrogenism is free androgen index - testosterone/Sex hormone binding globulin x 100

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17
Q

How would you diagnose CAH?

A

Be suspicious in cases of rapidly evolving hirsutism or where testosterone >5
High risk groups: Ashkenazi Jews or those with a family history of CAH

Test for 17-hydroxyprogesterone
If borderline then ACTH stimulation test

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18
Q

Discuss medical treatment of fibroids

A

TXA/NSAIDs
Coil
Hormonal contraception
Cyclical Progestogens
Ullipristal acetate - caution, can cause liver impairment
Relugolix–estradiol–norethisterone (Ryeqo) - approved by NICE 2022
Uterine artery embolisation

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19
Q

What are the risks when consenting for diagnostic laparoscopy?

A

Overall risk of serious complications in 2/1000

Serious:
However, up to 15% of bowel injuries might not be diagnosed at the time of laparoscopy.
Failure to gain entry to the abdominal cavity and to complete the intended procedure.
Hernia at site of entry (less than 1 in 100; uncommon).
Thromboembolic complications (rare or very rare).
Death; 3–8 in 100 000 women (very rare) undergoing laparoscopy may die as a result of complications.

Risk of bowel injury 0.4/1000
Risk of vascular injury 0.2/1000
Risk of death is 5 in 100,000

Frequent:
Bruising
Shoulder-tip pain
Wound gaping
Infection.

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20
Q

What is the rate of ureteric injury

….at laparoscopy
….when deep endometriosis/involving hydronephrosis

A

Generic rate around 1-2%
Up to 20% severe Endo

Pelvic brim or by internal os most common

Only 30% ureteric and 50% bladder injuries are recognised intra-operatively

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21
Q

What is the most common site of uterine perforation when performing SMM?

A

Anterior wall (40%)
Lateral wall (38%)
Cervical canal (36%)
Fundus 13%
Posterior wall 13%

22
Q

When consenting for laparoscopic morcellation, what are the serious risks?

A

1.Unintended morcellation of uterine sarcoma - difficult to interpret histology or confirm margins
2. Worsening prognosis of existing sarcoma - metastatic sarcoma carries a poor prognosis with a median survival of 18 months. Age-adjusted 10-year uterine sarcoma survival was 32.2% for women treated with morcellation compared with 57.2% for the non- morcellated group
3. Disseminated fibroids

Alternative - abdominal approach, contained retrieval in bag - no data to compare risks but theoretically does reduce

23
Q

What are pre-op rules about eating and drinking?

A

6 hours no eating
clear fluids up to 2 hours before

Clear fluids= water, tea/coffee without milk, fruit juice with no pulp

24
Q

What is the role of ketamine in managing post-op pain?

A

Consider a single dose (0.25 mg/kg to 1 mg/kg) of intravenous ketamine given either during or immediately after surgery to supplement other types of pain relief if:

the person’s pain is expected to be moderate to severe and an intravenous opioid alone does not provide adequate pain relief
or
the person has opioid sensitivity.

25
Q

What are routine recommendations for reducing the risk of surgical site infections?

A

-Patient to wash day before or day of surgery
-Consider nasal decolonisation alongside 2% ChlorHex if Staph aureus significant risk of infection
-Do not routinely hair remove - if necessary then clippers on the day
-Antibiotic prophylaxis if clean-contaminated or contaminated surgery

-Use sutures over staples in C/S to reduce risk of wound infection

-Use sterile saline 48 hours post op, then water OK to be used

26
Q

What are contra-indications to TEDs or mechanical prophylaxis?

A

-suspected or proven peripheral arterial disease
-peripheral arterial bypass grafting
-peripheral neuropathy or other causes of sensory impairment
-any local conditions in which anti-embolism stockings may cause damage – for example, fragile ‘tissue paper’ skin, dermatitis, gangrene or recent skin graft
-known allergy to material of manufacture
-severe leg oedema
-major limb deformity or unusual leg size or shape preventing correct fit.

27
Q

What is advice surrounding HRT pre-op?

A

Consider stopping HRT and oestrogen containing contraceptives 4 weeks pre-op for elective procedures to reduce VTE risk

28
Q

What is recommended LMWH post-op?

A

Risk assess
If high risk - 7 days LMWH or Fondaparinux
If cancer - 28 days LMWH

29
Q

When should primary amenorrhoea be investigated?

A

In absence of secondary sexual characteristics - age 14 (more likely to be endocrine)
If secondary sexual characteristics - age 16 (more likely to be anatomical)

30
Q

What is OHVIRA syndrome?

A

Obstructed HemiVagina Ipsilateral renal agenesis

Normal menarche - normally present age 15/16
Gradually increasing pelvic pain, mass arising from pelvis

31
Q

What is the prevalence of Endometriosis in fertile vs sub fertile women?

A

Endometriosis is an important cause of infertility, with a prevalence of 25–40% in infertile women, compared with 0.5–5% in fertile women

32
Q

What can be used in prevention of adhesions following Endometriosis surgery?

A

Oxidized regenerated cellulose

33
Q

What are the sections of the mental health act?

A

Section 2 - assessment, detain 28 days 2 x doctors and AMHP
Section 3 - treatment, 6 months 2 x doctors and AMHP
5(2) - holding power, by a single doctor for up to 72 hours
5(4) - holding power, by a nurse for up to 6 hours
Section 135 - public officers into a home
Section 136 - public officers from public space

34
Q

How do you diagnose menopause?

A

If over 45 and otherwise healthy, then diagnose on symptoms alone:
-perimenopause based on vasomotor symptoms and irregular periods

-menopause in women who have not had a period for at least 12 months and are not using hormonal contraception

-menopause based on symptoms in women without a uterus.

Do not use:
anti-Müllerian hormone
inhibin A
inhibin B
oestradiol
antral follicle count
ovarian volume.

Don’t use FSH if woman is taking combined contraception or high dose progestogen

If under 45, then consider use of FSH
Need 2 x samples 8-12 weeks apart

35
Q

What is the management of bleeding whilst on HRT?

A

Unscheduled vaginal bleeding is a common side effect of HRT within the first 3 months of treatment but should be reported at the 3-month review appointment, or promptly if it occurs after the first 3 months

Will need TVUS +/- biopsy

36
Q

What is the management of menopausal symptoms in women with breast Ca?

A

-Refer to expert
- Do not prescribe SSSRI in women on Tamoxifen

37
Q

What are the risks of HRT?

A

VTE
-Increased risk of VTE with oral HRT than baseline risk
-This is negated by transdermal HRT - offer to those with risk factors including BMI >30

Cardiovascular
-HRT does not increase risk of cardiovascular disease risk when started in those under 60
-does not affect risk of dying from CVD
-Oral Oestrogen is associated with a small increase in risk of stroke (but background risk is low)

Breast Ca
- Oestrogen only HRT is associated with little or no change in the risk of breast cancer
-Combined HRT can be associated with an increase in the risk of breast cancer, more likely with prolonged use >5 years
- Any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT.

Type 2 DM
- No association with T2DM or sugar control

Osteoporosis
-Risk of fragility fracture reduced whilst on HRT

38
Q

What are indications for transdermal HRT?

A

Indications for Transdermal Therapy

Individual preference
Poor symptom control with oral
GI disorder affecting oral absorption Previous or family history of VTE
BMI >30
Variable blood pressure control
Migraine
Current use of hepatic inducing enzymes medication Gall bladder disease

39
Q

In which groups of people is HRT contraindicated?

A

Do not prescribe hormone replacement therapy (HRT) in women with:
Current, past, or suspected breast cancer.
Known or suspected oestrogen-dependent cancer.
Undiagnosed vaginal bleeding.
Untreated endometrial hyperplasia.
Previous idiopathic or current venous thromboembolism (deep vein thrombosis or pulmonary embolism), unless the woman is already on anticoagulant treatment.
Active or recent arterial thromboembolic disease (for example angina or myocardial infarction).
Active liver disease with abnormal liver function tests.
Pregnancy.
Thrombophilic disorder.

40
Q

What is the Nd:YAG laser?

A

Produces light that can be transmitted through fiberoptic systems

The zone of damage produced by the incident beam of a Nd:YAG laser causes a homogeneous zone of thermal coagulation and necrosis up to 4 mm deep and lateral from the surface, making precise control difficult/

This laser is an excellent surgical instrument with which to perform tissue coagulation of large volumes of tissue - less good at vaporisation/incision

40
Q

If break through or erratic bleeding on HRT…

A

Double dose of progestogen
Represcribe sequential if newly on continuous HRT

41
Q

What antibiotics should be administered before a hysterectomy?

A

Cefuroxime + Metronidazole
Co-Amox
Clinda + Gent/ Quinolone
BUSY SPR states Gent + Metro

During the hour before skin incision
Repeat dose if blood loss >1500mls or 3 hours intra op

42
Q

At what points in a hysterectomy can the ureter be identified?

A

The ureter can be identified at the pelvic brim where it crosses the iliac vessels at their bifurcation.

It continues below the infundibulo-pelvic ligament on the posterior medial leaf of the broad ligament, and crosses under the uterine vessels before turning anterior and medially to enter the bladder.

43
Q

How is a diathermy injury to bowel managed?

A

Primary resection (normally segmental) and repair
Easier to identify areas of damage with diathermy - with monopolar there is higher risk of lateral spread

Injury from verses not always repaired

Primary closure in two layers using 3/0 Vicryl or PDS is sufficient for majority of small bowel injuries

Non-thermal injury
Bowel injury is less than 2 cm can be repaired transversely or longitudinally, although transverse closure to reduce the risk of stenosis is recommended
When the injury is more than 2 cm, it should be repaired transversely

When laceration is more than half of the diameter of the lumen, or when mesenteric blood supply is involved (regardless of the length of laceration), segmental resection and anastomosis is indicated.

44
Q

What are the recommendations for laparoscopic surgery in pregnancy?

A

In general - don’t delay
Increased risk to mother and foetus from non-operation (in appendicitis) than from operation

Laparoscopic surgery safe - most evidence for this in second trimester
In first trimester - normal entry then operate at 12mmHg

If risk of preterm birth, consider steroids
Don’t instrument uterus
Consider port placement based on gravid uterus

Ovarian cysts can generally be managed conservatively unless torted

45
Q

How long should medical records be kept for?

A

8 years (after death)
25 years in maternity
CTGs - forever

46
Q

Which complementary therapies are recommended by NICE for treatment of vasomotor menopause symptoms?

A

Black cohosh & isofalvones (but poor evidence)

No evidence to support: St John’s Wort, Ginseng, Vitamin E (can be harmful) and Kava Kava (causes liver damage)

47
Q

What investigations are required for premature ovarian insufficiency?

A

-Chromosome analysis (to look for Turners or Y chromosome), Fragile X
-Endocrine: Thyroid, 21-OHAb (if immune suspected)

48
Q

What are the management options of POI?

A

Risks

Cognition - HRT
Bone Health - Exercise and diet, Calcium, Oestrogen/COCP
Cardiovascular - HRT, annual monitoring of BMI and smoking
Sexual - Oestrogen, may require topical, counsel regarding Testosterone, lubricants
Fertility - spontaneous conception can still occur, oocyte donation and IVF
Pregnancy - If turners or post anthracycle chemo these will be high risk, need echo + consultant led care

HRT:
-Not been found to increase Breast Ca in pre-menopausal use
-17β-estradiol is preferred to ethinylestradiol or conjugated equine estrogens
-Use progestogen alongside

49
Q

How do you induce puberty?

A

Puberty should be induced or progressed with 17β-estradiol, starting with low dose at the age of 12 with a gradual increase over 2 to 3 years.

Transdermal oestrogen is preferred, start progestogens after 2 years or when breakthrough bleeding
COCP is contraindicated for induction

50
Q

What are risk factors for POI?

A

Ethnicity - higher African-americans and hispanic than caucasian
Smoking
Socio-economic - higher rates in more deprived populations

No correlation with age of menarche

MRCOG Part 2 (10 decks)

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