Group B - Reproductive and Benign Gynaecology Flashcards
Outline some investigations for suspected urinary incontinence
Urinalysis (infection)
Bladder diary (record intake, urine frequency / volume and any episodes of incontinence)
24 hr pad weighing (weigh before and after)
Ultrasound scan or cystoscopy
Invasive urodynamic testing (cystometry)
Outline the findings on invasive urodynamic testing for stress incontinence and urge incontinence in terms of:
- Bladder capacity
- Detrusor muscle activity increase
- Presence of leakage
- Provoked by…
- Volume of loss
Stress incontinence:
Bladder capacity = normal
Detrusor muscle activity increase = no large increase
Presence of leakage = present
Provoked by… = cough
Volume of loss = small-moderate
Urge incontinence:
Bladder capacity = decreased
Detrusor muscle activity increase = large increase
Presence of leakage = leakage with detrusor activity
Provoked by… = triggers e.g. washing hands
Volume of loss = often large
Outline management for urge incontinence
Often difficult to manage
Conservative:
- Sensible fluid intake
- Reduce caffeine and alcohol
- Alter home conditions e.g. downstairs toilets, commodes etc.
- Bladder retaining
Medical:
- Anticholinergic drugs e.g. Oxybutynin, Tolterodine, Propiverine, Solifenacin
- Botulinum toxin injections
- Electrical stimulation (posterior tibial nerve or sacral nerve)
Surgery:
- Enterocystoplasty (self-catheterisation)
- Urinary diversion e.g. ileostomy
Outline management for stress incontinence
Conservative:
- Sensible fluid intake
- Reduce caffeine and alcohol
- Alter home conditions e.g. downstairs toilets, commodes etc.
- Physiotherapy for pelvic floor exercises
Medical:
- Duloxetine (side effects)
Surgery (tend to skip medical):
- Tension free vaginal tape
- Burch colposuspension
Outline some symptoms associated with uterine prolapse
- Sensation of dragging / heaviness
- Lower back pain
- Urinary symptoms
- Urinary incontinence
- Faecal incontinence
- Bleeding / discharge
- Difficulties with sex
Outline the grades of uterine prolapse
Relates to entrance of vagina (introitus)
Grade 0: no prolapse
Grade 1: lowest part more than 1cm above entrance to vagina
Grade 2: lowest part within 1cm of entrance to vagina
Grade 3: lowest part 1cm below entrance to vagina
Grade 4: full external eversion = uterine procidentia
Outline some predisposing factors for prolapse
- Increase age
- Postmenopausal
- High parity
- Connective tissue disease
- Previous prolapse
- Obesity
- Smoking
Outline some complications of prolapse correction surgery
- Recurrence / failure to resolve prolapse
- Haemorrhage or vault prolapse
- Damage to local structures
- DVT
- New onset incontinence
Outline the treatment options for prolapse
May do nothing if all they need is reassurance
Conservative:
- Weight loss
- Pelvic floor exercises (physiotherapy supervision)
- Vaginal oestrogen cream
Medical:
- Vaginal ring pessary
Surgical:
- Surgery - depends on type of prolapse etc.
List some risk factors for cervical ectropion
- Adolescence
- Pregnancy
- COCP
Suggest examinations and further investigations for acute pelvic pain (gynae non-pregnancy related causes only)
Examinations:
- Abdominal / bimanual
- Speculum
Further investigations:
** PREGNANCY TEST**
- Clarify period timing for Mittelschmerz
- STI test for PID
- Urine dipstick
- Pelvic ultrasound (TVS/TA) for ectopic or cyst issues or PID abscess
- Consider MRI if suspect abscess
- Consider laparoscopic investigation in endometriosis
Suggest examinations and further investigations for chronic pelvic pain (gynae related causes only)
Examinations:
- Abdominal / bimanual (PID, endometriosis)
- Speculum
Further investigations:
** PREGNANCY TEST**
- STI test for PID
- Pelvic ultrasound (TVS/TA) for fibroids, cysts or PID abscess
- Consider hysteroscopy for smaller fibroids
- Consider laparoscopic investigation in endometriosis
- Consider MRI
Suggest some potential causes of sporadic and recurrent early pregnancy loss
** Idiopathic **
1st trimester pregnancy loss:
- Abnormal (aneuploid) karyotype
- Placental issues
- Genetic factors in parents e.g. balanced translocations
2nd trimester pregnancy loss:
- Weakened cervix
- Uterine abnormalities
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Chronic disorder e.g. diabetes, HTN, thyroid and SLE
- Infection e.g. rubella, syphilis
- Medication e.g. NSAIDs, Methotrexate
Suggest some investigations for sporadic and recurrent early pregnancy loss
(B) Screen for preexisting disease e.g. diabetes, thyroid
(L) Blood test for antiphospholipid antibodies and hereditary thrombophilias
(I) Vaginal ultrasound for uterine abnormalities
(P) Hysteroscopy / hysterosalpingography / sonohysterograms
(P) Cytogenetic analysis of products of conception (if abnormal then the parents should be karyotyped)
List some investigations to consider in suspected miscarriage
- Transvaginal ultrasound (establish foetal heartbeat and whether there are any foetal components within the uterine cavity)
If not present, check b-HCG
- Normal rise in b-HCG indicates normal growth but doesn’t exclude ectopic
- Fall in b-HCG may indicate miscarriage
- Only slight increase or a plateau may indicate ectopic
List some risk factors for ectopic pregnancy (factors making ectopic pregnancy more likely)
- Previous ectopic pregnancy!
- PID / scarring / genital infection
- Endometriosis
- Previous ovarian / tubal surgery
- Intrauterine device in situ (copper coil)
- PCOS
- IVF
Explain the different types of miscarriage
- Missed
- Threatened
- Inevitable
- Incomplete
- Complete
- Anembryonic
Missed miscarriage = foetus currently intrauterine but loss of foetal heartbeat (death) but absence of miscarriage symptoms
Threatened miscarriage = foetus currently intrauterine, PV bleeding but closed cervical os
Inevitable miscarriage = foetus currently intrauterine but heavy bleeding and pain, with open cervical os
Incomplete miscarriage = some expulsion of pregnancy tissue but evidence of retained tissue on USS
Complete miscarriage = full expulsion of pregnancy and no evidence of retained tissue on USS
Anembryonic miscarriage = gestational sac present, but no embryo
Outline the 3 main methods of miscarriage management
- Expectant management
- Allow 1-2 weeks for miscarriage to occur spontaneously
- Repeat b-hCG 3 weeks after symptoms settle - Medical management
- Misoprostol (prostaglandin receptor stimulator), single dose = softens cervix + uterine contractions
- Oral or vaginal suppository - Surgical management
- Manual vacuum aspiration only if < 10 weeks (local anaesthetic)
- Electric vacuum aspiration (general anaesthetic)
- Prostaglandins prior, soften cervix
- Provide anti-D prophylaxis if required
Outline the 3 main methods of ectopic management
- Expectant management
- Strict criteria (see next notes) - Medical management
- IM Methotrexate
- Cannot get pregnant for next 3 months - Surgical management
- Laparoscopic salpingectomy
- Laparoscopic salpingotomy
Outline the criteria for expectant management of ectopic pregnancy
- Easy and open access to gynae service
- Not ruptured
- Small <3.5cm
- No heartbeat
- No significant pain
- Low b-HCG
If want medical:
- Need to show absence of intrauterine pregnancy on USS
- Low-medium b-HCG
When does uncomplicated nausea and vomiting peak in pregnancy
Begins: 4-7 weeks
Peaks: 8-12 weeks
Resolves: 16-20 weeks
What pregnancy hormone is responsible for nausea and vomiting?
Hormone: human chorionic gonadotropin (hCG)
What conditions/situations can make nausea and vomiting worse during pregnancy?
- Molar pregnancy
- Multiple pregnancy
- First pregnancy
- Obesity
Outline hyperemesis gravidarum and state 3 factors that differentiates hyperemesis gravidarum from normal N&V
Hyperemesis gravidarum = severe form of nausea and vomiting that occurs <20 weeks
- Weight loss > 5% (compared to pre-pregnancy)
- Dehydration
- Electrolyte imbalance
