General gynaecology Flashcards

Question

After arranging a DEXA scan as part of your well woman check, you see a patient back to discuss her results. How do you proceed?

Answer 1

* Assess for RFs - FHx, low BMI, previous fragility fracture, menopausal, late menarche/early menopause, vitamin D and calcium deficiency, heavy soft drink intake, low physical activity/sedentary lifestyle, longterm corticosteroids * Use T-score to calculate FRAX score - T TREAT * Lifestyle modifications - stop smoking, optimise weight BMI 20-25, regular weightbearing exercises * Supplement Ca and vitamin D * Bisphosphonates - IV or PO. These should reduce the risk of fracture by 20%. * Monoclonal antibody (Denosumab) * MHT if vasomotor symptoms or other treatment inappropriate

Answer 2

Assess: * Competency * Ensure has a good understanding of reasons for a blood transfusion and consequence of not * Ensure no coercion - preferably discuss alone Manage: * MDT (depending on context) - obs/gynae team, anaesthetics, haematology, JW liaison, legal team * Clear advanced directive - signed in front of notes for accept/decline - RBCs - Plts - Albumin - Fractionated blood products - Immunoglobulins - Recombinant factor VIII - Autologous blood (stored prior or cell saver) - Cardiac bypass - ECMO - Fe - TXA * Focus on respecting autonomy - follow advanced care directive unless changes mind. May have NO BLOOD wristband on * Optimise Hb prior - Fe, EPO * Reduce blood loss - most experienced person present do procedure, minimally invasive, meticulous haemostasis, TXA, keep warm, avoid HTN and venous congestion, pre-op adjuncts e.g. Zoladex * Hypervolaemic haemodilution * Measure blood loss throughout * Utilise cell saver where able * Lower recourse to hysterectomy if bleeding * Limit blood collection afterwards

Answer 3

Assess: * Symptom diary - must be worse pre period and settle within few days of menses * Severity/impact on life * Screen for mental health aspect ?PMDD * Zoladex for 3m - if resolves can confirm if uncertain Manage: Conservative: * Exercise * Diet * CBT Medical: * Complementary: evening primrose oil, calcium supplement * Vitamin B6 * COCP (drosperinone containing, take continuous) * SSRI if symptoms mostly emotional * HRT (estradiol patch + utrogestan or Mirena) * GnRH analogue + add-back HRT * Bone density and CVD precautions/advice/tx * Spironolactone for fluid retention Surgical: * Hysterectomy, BSO + HRT (give zoladex +HRT first to ensure can tolerate) - ovarian conservation not recommended and drivers of symptoms. BSO alone not recommended as need HRT and progesterone for endometrial protection may worsen

Answer 4

* PCOS * CAH * Adrenal tumor * Ovarian tumor - Sertoli Leydig * External steroid use

Answer 5

History: * Assoc pain, bleeding * Other ulcerations prev or atm incl in mouth * Meds * Contact with anyone Exam: * Ulceration - appearance, location, pain * Vaginal mucosa, cervix and vulva * Lymphadenopathy * Mouth Differentials and investigations: * HSV - swab, viral PCR. Serology. * Syphilis - swab (dark ground microscopy), serology * LGV * Donavanosis * Lipschutz * Behcet's * VIN - biopsy * Vulval cancer - biopsy * Drug reaction e.g. Stephen Johnson - drug Hx * Crohn's disease - biopsy, Hx of IBD

Answer 6

Assess: * Sexual history, substance use, social situation * FBC, CRP, renal, LFTs, Hep B and C serology, HIV, syphilis * HVS - MC&S, NAAT * Endocervical for gonoccocal culture and sensitivities * USS pelvis ?TOA Counsel: * Important to treat to limit progression * Risks of pain, sepsis, TOA, LFT derangement * Long term risk of pain, adhesions, infertility, ectopic Manage: * Admit if more than mild * Triple ABx - ceftriaxone 1g IM (gonorrohoea), doxycycline 100mg PO BD 14days (chlamydia), metronidazole 400mg PO BD 14days (trichomonas/BV) * Analgesia * Contact trace - test and treat * Barrier contracpetion for 2weeks after treated * Keep IUD in situ unless not improving after 48hours * Re-test 3months as high risk re-infection * Contraception * Referral for social supports if needed

Answer 7

* Conservative - IVABx, time * IR (CT or USS) drainage - TV or TA * Laparoscopy + washout + drainage

Answer 8

* Ensure safety, support, confidentiality * Event timing, place, circumstances. Which orifices entered. Whether a condom was used. * Perpetrator - known to victim, any ongoing threat to victim or others * Any associated toxins - alcohol, cannabis, other * Survey for any injuries - sexual and otherwise * Assess and manage any instability first * Ascertain if want to provde police statement * Ascertain if would like forensic exam - do not shower. Refer to DSAC * Check for pregnancy, emergency contraception, follow up pregnancy test in 2weeks * Check for STIs (swabs, serology), STI prophylaxis, re-test in 4-6weeks (serology in 3-6months). Consider hepatitis B vaccine. Consider HIV PEP * Psychological counselling - ACC sensitive claim * Victim support, sleeping aides * Follow up

Answer 9

Assess: * Pain, discharge, bleeding * When pain happens - intercourse, tampons, speculums * Psychosocialsexual screen - any exacerbating factors, relationship difficulties, history of assault or trauma, MH screen * Obstetric and gynae history * Screen for persistent pain * Exam - cotton tip test, hymenal narrowing at all * STI swabs Manage: * MDT (and involve partner) - gynae, physio, therapist * Physiotherapy - exercises, dilators * Psychologist - CBT, sex therapy * Topical (or oral) neuropathic agents * Lubricant, LA gel for intercourse * Clear documentation in notes, make a plan for speculum, vaginal exams * Consideration given in trying to concieve

Answer 10

**Conservative** * Supervised PFM exercises for at least 12weeks - improves symtpoms, may not cure more advanced prolapse, may assist with recurrence reduction * Lifestyle modification - weightloss, constipation management, optimising chronic cough, avoiding heavy lifting * Ovestin - adjunct to all, very few contraindications but does need to self insert **Pessary** * Benefits - avoids surgical risks, easy to fit same day, can self manage * Risks - may interfere with intercourse, need to insert ovestin, discharge, erosion, need for long term reviews and changes **Surgical** Anterior/posterior repair * Benefits - 85% success * Risks - pain, bleeding, infection, injury to bladder/bowel, VTE, anaesthetic risks, impact on sexual function, unmasking stress urinary incontinence, recurrence, need to focus on recovery Hysterectomy * Benefits - success, reduces risk of endometrial/cervical pathology, short recovery time if done vaginally * Risks - pain, bleeding, infection, injury to internal organs, VTE, anaesthetic risks, vault dehiscence, fistula Sacrospinous fixation * Benefits - success for central compartment/vault prolapse, vaginal access, quicker recovery * Risks - pain, buttock pain, bleeding, infection, injury to internal organs or pudenal neurovascular bundle, VTE, anaesthetic risks, impact on sexual function as changes vaginal axis Sacrocolpo(hystero)pexy * Benefits - gold standard success for central compartment/vault prolapse, able to retain uterus if hysteropexy, less impact on sexual function, can be done open or laparoscopic * Risks - pain, bleeding, infection and osteomyelitis, injury to internal organs, VTE, mesh erosion, fistula, recurrence, hernia formation, anaesthetic risks, longer recovery time Colpocleisis * Benefits - complete closure of vagina, often seen as last resort and very effective * Risks - pain, bleeding, infection, injury to adjacent organs, VTE, recurrence, if retained uterus inability to sample cervix or uterus

Answer 11

A pessary is a soft, flexible silicone device that is placed in the vagina to help support the bladder, vagina, uterus, and/or rectum. It may be the only management a woman needs for prolpase management, it also may be used whilst awaiting a surgical procedure. Women who have gone through menopause, are recommended to use vaginal estrogen to prevent injury to the vaginal tissue. The estrogen cream makes the lining of the vagina thicker and healthier this is used at night, twice a week Side effects of a pessary can be vaginal discharge, irritation and discomfort, trouble passing urine or your bowels, and scarring over or around the pessary You can be taught how to insert and remove your pessary. If you are able to care for your pessary at home, we typically recommend that you take it out and clean it daily. You should use a mild soap with water, rinse and dry it completely, and reinsert it into the vagina the next morning. It is OK to keep it in for a longer period of time but never more than 3 months at a time. Sexual activity is possible with a ring pessary insitu. if there is difficult with sexual activity you can remove and replace it If you are unable to remove and reinsert your own pessary, we will want to see you in the office for cleaning and examination every three months. We can check your ability to do so in the clinic and ensure you may empty your bladder prior to leaving. We will provide you with written information about pessary management and a number to contact if there are any issues when you are at home.

Answer 12

History * constant vaginal leakage, smells like urine Exam * Fistula seen * Methylene blue tampon test Investigations * Cystoscopy * EUA * MRI * Intravenous pyelogram or cystourethrogram Management * If small may manage conservatively - IDUC, anticholinergics, * Surgical repair timing depends on tissue integrity - ASAP if obstetric, 6weeks delayed if gynaecological. * Catheterise defect, excise surrounding epithelium. Close defect with a Martius vaginal flap, suture in layers

Answer 13

Pelvic floor exercises Ovestin Pessary with continence knob * Benefits - can fit in clinic, avoids surgical risks, les invasive, reversible * Risks - dislodgement, discomfort, ulceration, need for ovestin cream, serial reviews, Retropubic vaginal sling - mesh or autologous from rectus sheath or tensor fascia lata * Benefits - 80% success, autologous avoids mesh erosion * Risks - pain, bleeding, infection, bladder injury 10%, VTE, recurrence, urinary retention, de novo urgency, mesh erosion TOT Burch colposuspension Periurethral bulking * Benefits - few surgical risks, may be done in clinic setting * Risks - Lasts ~ 6months , infection, urinary retention Articifical urinary sphincter

Answer 14

Bladder retraining Ovestin Anticholinergics - oxybutynin, solifenacin, mirabegron Bladder botox Posterior tibial nerve stimulation

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General gynaecology Flashcards

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