GYN Flashcards

1
Q

Minimum evaluation of complaint of urinary incontinence

A

History: leak as social problem; severity and goals; frequency (8x/day nml), nocturia (1x/night nml), dysuria, urgency; aggravating factors; timing of leakage; PMH–DM, MS spinal cord trauma/injury; PSH–spine, radiation, bladder surgery; meds–diuretics, EtOH, narcotics, antihistamines, caffeine, alpha agonists/blockers, CCB
UA and cx
Exam: obesity, prolapse–assess all support, degree of estrogenization, neuro-exam; demonstration of SUI, measurement of urethral mobility, PVR (abnml >150)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

UUI tx

A

anti-muscarinic meds: oxybutynin/tolterodine/solifenacin
block parasympathetic M2/m3 receptors to inhibit involuntary detrusor contraction
SE: dry mouth, eyes and constipation

Contra-indications: narrow angle glaucoma, urinary retention gastric retention/obstruction

Beta 3 adrenoreceptor agonists (mirabegron)
relaxes detrusor mm and increases bladder capacity

do not use if uncontrolled severe HTN, renal, liver disease

Botox more likely to have complete relief of UUI
SE UTI and retention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

behavioral for UUI and/or SUI

A

pelvic floor exercises PT
weight loss
dietary/fluid modification/bladder training
devices

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

surgical for UUI and/or SUI

A

SUI: urethral bulking agents or mid urethral sling
lack of urethral mobility associated with increase in failure of sling–do bulking agents instead

UUI: sacral neuromodulation ofr refractory UUI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

simple fistulectomy procedure

A

close in 3 separate layers
rectal submucosa, muscularis, vaginal mucosa
anterior rectal wall edges inverted with interrupted submucosal 3-4.0 vicryl
2.0 vicryl in muscularis of anterior rectal wall to remove tension from first suture line
puborectalis muscle reapproximated to remove tension off underlying layers
vaginal mucosa re-approximated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

treatment of ectopic pregnancy

A

expectant management: stable patient hCG <200; 88% will experience spontaneous resolution

methotrexate: folate antagonist (inhibits dihydrofolate reductase which converts dihydrofolate to tetrahydrofolate)
SE: stomatitis and conjuctivitis; rare–gastritis, enteritis, dermatitis, pneumoniitis, alopecia, LEFTs, bone marrow suppresion
avoid folate, NSAIDs, sunlight

surgery: ruptured, unstable, stable intact patient with counseling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

contraindications to MTX for ectopic

A

absolute: IUP, immunosuppresion, blood dyscrasia (anemia/leukopenia/thrombocytopenia), sensitivity to mtx, active pulmonary disease (not asthma), active PUD, clinically important hepatic or renal dysfunction, breastfeeing, ruptured ectopic, hemodynamically unstable, not reliable for follow up

relative: FHR, size >4cm, hCG>5,000, declines blood transfusions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Dosage MTX for ectopic

A

single dose: 50mg/m2 IM day 1; check hcg D4 and D7–should drop >15% , follow weekly thereafter
Can give another dose if inappropriate drop

two dose regimen: 50mg/m2 on D1 and D4; consider for hCG>3000 or adnexal mass >2cm;

multidose: 1mg/Kg of D1, 3, 5, 7/leucovorin .1mg/kg on D2, 4, 6, 8–used for cornual or cervical ectopics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

heterophile hcg

A

usually from animals (think lab techs, vets, farmers)
urine pregnancy test will be negative

serum levels usually <1000

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

CREST tubal ligation failure reates

A

(type; 5 yr failure per 1000; 10 year failure per 1000; ectopic risk per 1000)

Non PP BTL; 13/-;-
PP BTL; 6; 7.5; 1.5
Copper IUD; 14;-;-
Progesterone IUD; 5; -;-
bipolar cautery; 16.5; 25; 1.7-17
bands; 10; 20; 7.3
clips; 30; 40; 8.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

most common complication after GYN surgery

A

SSI

superficial incisional, deep incision abscess, pelvic or vaginal cuff cellulitis or abscess

RF: BMI >=30, periop hyperglycemia, coexistent infection, smoking, vaginal colonization, depth of subQ >=3cm, MRSA, immunosupression, poor nutrition

pre op measures: treat all infections remote from surgical site; no shaving–clipping of hair if needed; control blood sugar <200; shower/bath with soap/antiseptic night before surgery; vaginal prep with 4% CHG or iodine, skin prep, abx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

surgical procedures requiring abx ppx

A

hysterectomy, AP repair, vaginal sling, laparotomy (no entry into bowel/vagina–may consider)

Ancef 2g (3g if >120kg)

hsg chromotubation if hx of PID or abnml tubes found–doxy 100mg BID x5 days

induced Ab or pregnancy d&C; doxy 200mg pre procedure x1

redose ancef if ebl >1500 or surgery >4hrs

PCN allergic: clinda 900mg x1 + gent 5mg/kg x1–redose clinda at 6hrs
can use aztreonam 2g instead of gent redose at 4hrs

MRSA–give vancomycin ppx 15mg/kg x1
can use flagyl 500mg)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

urovaginal fistula work up

A

dual tampon test: saline and dye in bladder; pyridium and tampon in vagina–blue is from bladder; orange is from ureter

retrograde pyelography: ureteral integrity

IVP: less useful fro identifying and disruption fo urethral integrity

CT urogram: identify fistula site (cysto to rule out bladder injury)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

medical management of fibroids

A

address bleeding symptoms

GnRH ANTAGONIST (elagolix 300mg) with hormonal add back (1mg estradiol/0.5mg norethindrone); spproved x2yrs
SE: hot flushes and headache
90% with <80cc monthly blood loss at 1 year

Mrena IUD: expulsion higher if myomas distort uterine cavity
40% amenorrhea by 1 year

OCPs

TXA: antifibrinolytic–presents fibrin degradation 1300mg x5 days

bleeding AND bulk
GnRH agonist (Lupron): limited to 6 months iwthout add therapy and 12mo with –use as a bridge to other therapies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

complications of UAE

A

major 12%
unplanned hysterectomy (uterine perforation/intraperitoneal injury); UA perforation/hemorrhage

rehospitalization; bacteremia from arteriotomuy; myometritis
ovarian failure, PE

minor 21-64% symptommatic degeneration, postembolization syndrome pain fever nausea, myometrial infarction/necrosis, pelvic infection, discharge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

non ovarian cancer causes of elevated CA-125

A

endometriomas
pregnancy
PID
non-gyn malignancy
inflammatory conditions SLE/IBD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

gonorrhea treatment

A

dual therapy no longer recommended

ceftriaxone 1g IM x1

expedited partner treatment; 800mg cefixime PO x1 (plus 100mg doxycycline PO BID if chlamydia unknown)

expedited partner treatment

abstain x7 dys

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

AUB

PALM-COEIN

A

Polyps
Adenomyosis
Leiomyoma
Malignancy

Coagulopathy
Ovulatory dysfunction
Iatrogenic
Not otherwise specified

EMB >45; younger if RF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

benign breast lesions

A

non-proliferative cysts
proliferative without atypia: fibroadneoma/intraductal papilloma
atypical hyperplasia–atypical ductal hyperplasia/atypical locular hyperplasia

dense breast confer moderate increased risk of malignancy

atypical ductal and lobular hyperplasia have 4 fold risk of of invasive malignancy; lobular carcinoma in situ is a risk marker for future malignancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

work up of a breast mass

A

imaging based on age:
diagnostic mammogram if >30; US usually required for further evaluation
US <30; determines if solid or cystic

aspiration: indicated for complex cyst or simple cyst that is symptommatic or patient anxiety

excision/biopsy: suspicious solid palpable mass, non-palpable suspicious mammo finding; aspiration with BI-RADS 3 (bloody fluid if positive cytolgoy, mass fails to resolve), associated with bloody nipple discharge or ulceration

atypical hperplasia or LCIS
annual mammogram >30
clinical breast exam q6-12mo
RR recommended (Tamoxifen)
annual MRI if lifetime risk >20-25%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

most common cuase of bloody nipple discharge

A

benign intraductal papilloma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

most common cause for a solid breast mass

A

fibroadenoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Breast MRI indicated

A

BRCA1/2
1st degree relaitve is BRCA1/2 and patient not yet tested
lifetime risk of breast cancer >20%
chest radiation between 10-30yrs
cowden and other genetic syndromes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

complete v partial mole

A

partial: 69xxx or xxy; fetus can be present; uterine size is small; theca lutein cysts are rare; GTN risk <5%

complete: 46xx or xy (paternal only); fetus absent; large uterus, theca lutein cysts are common; GTN risk 15-20%

theca lutein cysts are from high hcg levels

treatment of choice for molar: suction curettage followed by sharp curretage; hysterectomy if child bearing complete

post op followup: contraception
hcg weekly until negative
for partial can stop after first negative hcg
for complete do monthly x3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
concern for post molar GTN
increasing hCG>10% accross 3 values over a 2 week period plateauing hCG: 4 measurements that remain within 10% over at least 3 weeks
26
GTN
invasive mole choriocarcinoma PSTT epithelioid trohpoblastic tumor
27
FIGO and GTN
age duration from antecedent pregnancy type of pregnancy pre treatment hcg largest tumor size site of mets number of mets history of failed chemo
27
most common causes of cancer death in women
lung breast colon pancreas ovary
27
histopathology of lichen sclerosis
loss of rete pegs, thinned epidermins, hyperkeratosis
27
histopathology of papillary hidradenoma
appears malignant under low poer but benign on high power
28
histopathology of condyloma
koilocytosis: small shriveled nuclei in upper layer of epidermis papillomatosis: exaggerated rete pegs acanthosis: increased melanin layer hyperkeratosis: thickened keratin layer parakeratosis: nuclei in superficial layer of epidermis
28
histopathology of dysgerminoma
lymphocyte infiltrated stroma (large vesicular cells with clear cytoplasm that resember fried eggs)
28
histopathology of krukenburg tumor
signet ring cells
29
coffee bean nublei
brenner tumor and granulosa cell tumor
30
langhans giant cell
multinucleated gian cell with nuclei arranged along periphery of cell with opening at one end (horse appearance) pathognomonic for TB
31
schiller duval bodies
endodermal sinus tumor
31
call exner bodies
granulosa
32
psammoma bodies
LMP; nuclear atypica and cellular proliferation, invasive if breaches basement membrane
32
heavy menstrual bleeding and enlarged irregular uterus. what is ddx.
pregnancy pregnancy complications myomas adenomyosis adhesion disease giving impression of enlarged uterus adnexal mass rather than uterine mass uterine malignancy
32
complications of UAE
fever--degeneration of fibroid or infarction of myometrium, bacterial seeding into the myoma bed or vessel, uterine perforation bleeding or hematoma at arteriotomy site myometrial necrosis perforation of uterine arty by catheter, bleed, hematoma perforation of uterus and bowel injury
33
treatment options for symptomatic myoma
hormonal menstrual regulation oral TXA, NSAIDs leupron--amenorrhea in most patients, improved hct, myoma size reduction (50% in 3 months); cannot use >12 months due to osteoporosis GNRH antagonist with add back therapy, can use up to 2 years UAE myomectomy hysterectomy
33
characteristics of a normal period
every 21-35 days; <80cc in blood loss volume
34
quick facts of sacrospinous ligament fixation
done on R side bc sigmoid colon on L vaginal apex is sutured posterolaterally not as effective foe anterior wall wupport; post op recurrence of cystocele, loss of UVJ support and stress urine incontinence is common enterocele may recur injury to pudendal nerve may occur as it courses beneath the sacrospinous ligament near the point of suture fixation
35
quick facts on uterosacral ligament suspension
2-3 permanent sutures placed through each uterosacral ligament 1.5cm posterior and medial to ischial spine; then suture passed through the anterior muscularies and posterior endopelvic fascia; sutures are tied to reapproximate the anterior and posterior muscularis and closes potential enterocele lessens subsequent problems with SUI ureteral obstruction is most common complication; cystoscopy should be done, removal of most lateral suture should be done sacral nerves can be ligated if sutures are placed lateral tot he ligament or too deep in the pelvic sidewall
36
sacral colpopexy
affixing mesh graft to anterior and posterior dissectionsof the vaginal apex (or cervix) and via a retroperitoneal tummel, fixation of the graft to periosteum of the anterior sacrum with dissection posteriorly down to rectovaginal septum for mesdh placement can reduce rectocele obliterates cul de sac complications: bleeding from middle sacral vessels in sacral periosteum; mesh erosin into vaginal apex urethropexy (Burch or similar) should always be done
37
complication of SUI procedures
cystitis vascular complications/bleeding bladder or urethral performation urinary retention voiding dysfunction new onset UUI mesh erosion--vaginal bleeding, pelvic pain, non-healing granulation tissue, dyspareunia, partner irritation mesh erosion <0.5cm; vaginal estrogen up to 12 weeks >2cm in size; removal of exposed portion and tension free closure
38
5 compartments to evaluate for pelvic organ prolapse
central vaginal vault or uterine prolapse anterior compartment prolapse (cystocele) posterior compartment prolapse below the rectovaginal septum apex (rectocele) above the apex (enterocle) outlet--perineal body and levator musculature
39
indications for inpatient management of PID
acute peritoneal signs pregnant patient other surgical emergency not excluded failure of outpatient management/no response to oral therapy TOA inability to comply with outpatient management n/v
40
painful bladder syndrome
pain, urgency, frequency do UA Ucx PVR with US cysto with hydrodistension not required glomerulations (petechiae) non specific Hunner ulcers, diagnostic amitryptiline first line Elmiron
41
ddx of heavy menstrual bleeding and enlarged uterus
pregnancy including mole myomatous infiltration of the uterus adenomyosis adhesive disease giving impression of uterine enlargement adnexal mass uterine malignancy
42
ddx for AUB-H
endocrinopathy oligo-ovulation or anovulation coagulopathy adenomyosis endometrial lesion cervical lesion PALM COEIN
43
contraindications to endometrial ablation
endometrial hyperplasia or carcinoma active pelvic infectin prior procedures which thin the myometrial wall and increase risk of perforation or extra-uterine injury current pregnancy congenital uterine anomalies endometrial cavity size limitations specific to the proceure desires future childbearing relative: ovulatory dysfunction, obesity, tamoxifen use, younger age (higher failure rate)
44
abx for infected sling mesh
mesh removal cipro or levo and flagyl x7 days
45
bleeding from TVT
usually from branches of vaginal artery and inferior vesicle artery (besicle neck and urethra) usually self limiting hematoma can develop in space of retzius obturator vein and artey are also adjacent the sites of dissection and are more likely to cause hematoma formation need to do meticulous dissection and the medial aspect of the sub pubic angle
46
important complications of sling
urinary retention if too tight; manage conservatively for 6 weeks insufficient tension: repeating urodynamic testing and cystoscopy (exclude neuromuscular conditions) - may replicated on one side of mesh - can add periurethral bulking agent delayed complication: erosion of sling into bladder/urethra; always consider with new onset hematuria or pyuria
47
what should every stage III or greater prolapse have checked
PVR for urinary retention ; PVR >100 can be suggestive of voiding dysfunction or detrusor weakness
48
chronic urinary retention
think CVA, MS, DM...or prolapse management: pessary or surgery for pelvic organ prolapse; evaluate for occult SUI prior to surgery
49
when does peritoneum re-epithelialize?
48-72hrs can consider closure of subcutaneous tissues to decrease hematoma or seroma formation; can also decrease with closed suction drainage good surgical technique and hemostasis are best
50
suture review
gut suture: rapidly absorbable; dissolves completely within 3-4w; little tensile strength--good in vagina delayed absorbable: lose 50% by 2w; absorption by hydrolysis polydioxanone: 10-12w; but half life is 3w permanent: myoln polypropylene; tensile strength for at least 2 months
51
fascial dehiscence what do you do
take back, clean/debride; collect for cultures re-approximate WTD; then wound vac once re-epithelialized (or place at same time) abx: ampicillin or cephalosporin and gentamycin
52
you think you perf during a suction D&C, what do you do
stop the suction currettage alert staff that you have encountered more bleeding and everyone needs to be on alert for equipment/supplies/blood inspect cervix and vagina for lacerations sharp curretage to assess for retained products--ideally under ultrasound or even laparoscopy no suctin currettage uterotonics; oxytocin not super effect early gestation -- methergine or hemabate better uterine massage can be helpful, if not try tamponade with foley balloon do at least diagnostic lap if suction currettage is what perfed if blunt instrument, may not be necessary
53
16yo with saddle injury and blue mass at vulva
hematoma--don't open it need thorough physical exam including pelvic exam--likely needs EUA, external, vaginal and rectum, bimanual to assess retroperitoneum possible diagnostic laparoscopy serial labs possible CTAP possible angio and IR embolization
54
energy in surgery
bovie: high frequency monopolar electrical current by a radiofrequency generator--vaporize or boil cellular water in tissues a centimeter or more away from the instrument itself Kleppinger bipolar: incorporates botht he active and return electrode in the same instrument so that no current is passed through the patient's body--in theory should be less thermal spread Ligasure/gyrus: advanced bipolar which incorporate cutting device; theoretically less thermal spread Harmonic scalpel: ultrasonic energy by vibration of the blade at over 55,000 Hz to produce protein denaturization; somewhat less effective as a hemostatic device
55
Novasure
high frequency radio energy to heat and desiccate the endometrium, like the bovie bipolar electrode deployed as two wings within the endometrial cavity the generated energy is standardized s is the time of the ablation cycle dessicated endometrium is evacuated through the instrument size and shape of the endometrial cavity will affect the outcome fo the ablation don't use in these conditions: very small uterine cavities in which there is difficulty in deploying the wing electrodes; menopausal women; uteri with a known or suspected congenital anomaly; irregular uterine cavity; large cavity; any situation where the integrity fo the endometrial cavity is in doubt warning signals and automatic shutdowns should be carefully evaluated and the procedure should not continue without careful evaluation hysteroscopic assessment fot he endometrial cavity may be needed procedure should be terminated if there is any concern of cavity integrity or of proper function of the device
56
TOA and PID
ddx: PID, TOA, ectopic pregnancy, septic abortion, appendicitis, pyelonephritis, perforation of viscus due to infection or PUD, cholecystitis, pancreatitis, pneumonia evaluation: H&P, CBC/chemisry/amylas/lipase/LFTs/hCG, cultures of cervix, UA/cx, blood cx imaging studies as needed determine if surgical abdomen--ifyes proceed for ex-lap after IV access and initiation of abx abx: ceftriaxone, doxycycline, flagyl; gent/clinda/amp TOA: IV abx x72hrs; if not improving, consider IR drainage or laparoscopic drainage; conservative is better if <7cm treatment failure: new onset or persistent fever, persistent or worsening abdominal/pelvic pain, enlarging pelvic mass, persistent/worsening leukocytosis, suspected sepsis acute abdomen, signs of sepsis--proceed with laparotomy--copious irrigation and debridement; look for meckels diverticulum, ruptured appendicitis, diverticulitis drain placemetn appropriate if residual tissue inflammation present following debridement                                          
57
watery discharge after surgery, what is ddx?
incomplete closure of vaginal cuff and leakage of peritoneal fluid, physiologic leukorrhea following procedure, vaginitis, vescio-vaginal fistula, uretero-vaginal fistula, recto-vaginal fistula dual tampon test: tampon in vagina; gently fill bladder via catheter with methylene blue--blue dye on tampon means vesciovaginal fistula give indigo carmine dye IV or PO pyridium tablets; presence of dye on the tampon indicates a uretero vaginal fistula cysto allows visualization of the fistula CT urogram place foley to decompress bladder; sponatenous healing may occur with small fistulae--maintain 4-6w if drainage still present after catheter removed; re-insert and observe until 12w post op--allow for residual suture material to absorb and inflammation to resolve repair is by three layer closure: escision of the fistula tract to fres tissue margins; reapproximation of bladder submucosa with 3.0 vicryl; reapproximation of the bladder muscularis with 2.0-3.0 suture; closure of the vaginal mucosa with similar suture uretero-vaginal fistula cysto to exclude bladder and CT urogram to identify site of ureteral injury low ureteral injury, place stent; 30% heal in 3-4w; high ureteral injury; PCN for renal decompression and ureteral surgery 12w post op
58
rectovaginal fistula
anal--at or just above the sphincter low rectal--in the lower half of the rectovaginal septum high rectal--in the upper half of the rectovaginal septum suspect if complaint of: passing flatus from vagina, chronic vaginal fluid drainage at weeks to months following operation in this area, passage of stool per vagina, persistent pain or irritation in the introital or low posterior vaginal area diagnostic consideration: assessment of the integrity of hte anal sphincter is important; physical exam and sonography insert water into the vagina, retract anterior vaginal wall; place air in the rectum and look for location of bubbles high rectal sites must be evaluated by anoscopy or sigmoidoscopy surgical repair is undertaken for anal and low rectal fistulae most commonly by simple excision and layered closure--all inflammation must be allowed to subside, sometimes requiring a 12w delay in repair; if infection present, treat with abx; tissue cleanliness with sitz baths is maintained int he interim; bowel prep before repair; complete excision of the tract with 2cm margins is essential to ensure proper healing and avoid recurrence; rectum and vagina must be separated completely per the same principle as in repair of vescio-vaginal fistula--rectal submucosa is repaired, a separate muscular layer developed int he RVS and the vaginal mucosa closed as a third layer. Do not overlap suture lines
59
hysteroscopy
perforation: if done during cervical dilation and/or blunt instrument ovservation may be all that is necessary; if done with sharp instrument or electrosurgical instrument or with a morcellator laparoscopic evaluation is indicated hysteroscopy with normal saline (only truly iso-osmolar irrigant/distension media) should not carry a risk fo significant hyponatremia but with all irrigant fluids carries risk fo intravascular fluid overload and thir spacing fluid overload: pulmonary edema, acute decompensated heart failure, dilutional anemia; hypothermia with increased acidosis and cardiac arrhythmias mechanisms leading to overload: rapid instillation of fluid under pressure into an opened vessel in themyometrium (usually vein) which usually occurs toward the base of a myoma under resection where the primary vessels are encountered, and which can also occur during endometrial ablation; intraperiotneal instillation of fluid which is rapidly absorbed into circulation by the periotneum--trans fallopian drainage, unrecognized uterine perforation, electrolyte poor fluids (mannitol--use when monopolar cautery) use lowest pressure that allows adequate visualization (usually 70-80mm Hg) protocols to minimize fluid overload: obtain preoperative Na and Hgb baseline; employ an automated low pressure fluid irrigant system with continuous monitoring of fluid balance; assess fluid balance/deficit every 3-5 min during the procedure; limit oeprating time to 45min; at deficit of 750-1000cc cease oepratio nand assess post operative Na and hgb Na levels below 120 carry high risk of hyponatremia seizure and are managed with 3% repletion slowly and at 20-25% of the volume fo estimated water deficit only to a maximum of 100-150cc if active bleeding following termination, place foley catheter
60
ddx adnexal mass
physiologic ovarian cyst, benign neoplasm, malignant neoplasm, endometiroma, abscess, fallopian tube abnormality or a periotneal or congenital remnant cyst US findings suggestive of neoplasia: thick septations >2-3mm or complexity of the internal architecture, irregularity of the internal cyst wall or nodularity, bilateral cysts increase likelihood of neoplasia, doppler flow often increased, size >10cm, solid and cystic components, presence of ascites general guidelines based on cyst size: cyst <5cm not neoplastic in 95% of cases; usually physiologic; cysts>10cm should unergo surgical evaluation and removal; simple cyst <10cm in post menopausal woman can be observed IF patient is asymptomatic and CA-125 normal; expectant managemetn can be done for suspected endometrioma, mature teratoma or hydrosalpinx if asymptomatic and usually if <5cm; for cysts between 5-10 cm surgery should be done if suspicious findings by imaging, symptoms, tumor markers
61
pelvic mass in pregnancy
simple cyst, teratoma, corpus luteum, hemorrhagic cyst, cystadenoma, epithelial ovarin tumor complex cyst identified in first trimester should be re-evaluated at 17-18w; operation is safest after 18w characterize the mass by ultrasound can do expectant management of asymptomatic endometriomas, mature teratomas and corpus luteal cysts if diagnosis is reasonably certain removal of corpus luteum prior to 8w requires progesterone supplementation dysgerminoma: 75% malignant germ cell tumors, bilateral 10-15% of time
62
age specific considerations of solid adnexal mass
20-30: exclud pregnancy; benign germ cell tumor-teratoma, fibroma, thecoma, brenner; risk of malignancy small 40-50: exclude pregnancy, change of malignancy still <1% 50+: always supect malignancy adolescents: first exclude pregnancy, infection, torsion; persistnet complex mass: mature teratoma, immature teratoma, endometrioma; if more than 50% solid are considered malignant until proven otherwise--germ cell tumors (dysgerminoma), sex cord stromal cell tumors (juvenile granulosa cell, steroli leydig) tumor markers in adolescent with solid mass: hcg, AFP, LDH
63
patient risk factors for adnexal mass malignancy
increasing age (over menopause) family history of breast or ovarian cancer BRCA1/2 pos increased ovulatory age (nullip, early menarche, late menopause) endometriosis and infertility
64
Ectopic pregnancy
ddx: early IUP with implantation bleeding, threatened SAB, incomplete SAB, completed SAB, multiple gestation involving SAB of one twin, ectoopic, molar, heterotopic tests to order: hcg titer, serial, blood type and Rh, pelvic US, CBC, metabolic panel MTX: patient must e stable, no medical contraindication to MTX, desires future fertiligy, able to comply with follow up, cannot have blood dyscrasia, liver disease, PUD, renal insufficiency, chronic pulmonary disease, breast feeding, immunodeficiency relative contraindications: hcg titer >5000, mass >3-4cm, cardiac activity surgery: salpingectomy v salpingostomy; IUP rats higher with salpingostomy but recurrent ectopic also higher...only reserved for patients with contralateral tube is damaged
65
pregnancy test positive; enlarged bluish cervix
ddx: cervical pregnancy, large nabothian cyst, congenital anomaly of the cervix, leiomyoma, malignancy profuse painless vaginal bleeding is common presentation of cervical pregnancy; US findings show an hourglass shaped uterus and ballooning of the cervical canal MTX first line if stable surgical management: preop type and cross, large bore IV access, consetn for possible hysterectomy; excise cervical lesion control bleeding by: uterine packing, lateral cervical suture placement to ligate cervical branch vessels; placement of cervical cerclage for tamponade, angiographic arterial embolization, if laparotomy required, uterine artery ligation, abdominal hysterectomy if necessary if choosing MTX; treat as inpatient, hemorhage can be significant --serial three dose regimen rather than single dose treatment is preferred; if bleeding presists after MTX dilation and ECC are performed, consider UAE, hysterectomy
66
cornual ectopic
consider potential for hemorrhage and uterine rupture--cornual excision is generally successful, hysterectomy may be necessary usually done via laparotomy; use vasopressin (20u in 1ml vial; mix with NS--use less thatn 5-6IU)--potent vasoconstrictor, causes bradycardia, loss of peripheral pulses, hypotension, cardiac complications--ephedrine, glycopyrrolate risk of subsequent pregnancy with uterine rupture should be discussed but actual risk unknown medical management--multi-dose MTX protocol
67
8w pregnant; 14w size uterus what is ddx
wrong dating, multi-fetal pregnancy, presence of uterien mass, large adnexal mass making the clinical uterine assessment, molar pregnancy US findings: complete mole--hydropic placental changes suggestive of mole and absence of fetus/embryo; partial mole will have sac +/- fetus with simlar placental changes after evacuation of a molar pregnancy, surveillance with serial hCG assay--partial mole GTN may develop in 3-8% of cases, and with complete mole in 8-20% cases GTN: invasive mole, choriocarcinoma, PSTT, epitheloid trophoblastic tumor
68
EIN tx
medical: oral progestin therapy: megestrol 40-200mg/d in divided doses for 6 months; MPA 10-20mg daily 52mg LNG-IUD (first line choice due to higher regression rates) Depo medroxyprogesterone acetate 150mg IM q3mo serial endometrial samplying every 3-6mo regression of EIN with medical management is 80-90%
69
Nerve injuries
transverse incision (pfannenstiel or cherney) dissection fo the anterior rectus sheath may injure iliohypogastric and ilioinguinal; can also be injured by entrapment femoral nerve: deep pelvic surgery, usually abdominal hysterectomy, compression fo the femoral nerve against hte pelvic sidewall wih deep or lateral placement ofthe retractor blades; risks: thin patient, wide pfannenstiel ro Maylard incision, >4hrs surgery time, narrow pelvis, poorly developed rectus muscles, self retaining retractors sensory deficit of anterior/medial thigh; motor symptom is weakness ofhip flexion and knee extension can also occur from excessive hip abduction during vaginal surgeries pudendal nerve; risk of entrapment or injury during sacrospinous ligament fixation; perineal/mons and vulvar pain--worsens when seated sciatic nerve: candy cane stirrups in vaginal surgery--external rotation of hip and incomplete flexion at the knee; motor symptoms include weakness of knee flexion and dorsiflexion of foot; sensory symptom invovles the plantar foot peroneal nerve: allen stirrups, pressure of leg rest on the upper lateral tibial area during surgery; produces a foot drop obturator nerve L2-4; paravaginal repair, radical pelvic dissection, trans obturator sling urethropexy, inability to adduct thigh, numbness of inner thigh
70
bladder injury repair
superficial thermal: you can only see what you see, make sure to do cysto to confirm it is superficial; thermal injuries may not fully present at the time of injury; if small, can oversew; most conservative approach would be to excise the area and do fullthickness closure in layers and leave foley in place; do cystogram prior to removal
71
places where ureteral injury can occur
crossing of ovarian vessels in the IFP ligament crossing of the uterine vessles adjacent tot he site of ligation paracervical web at the level of the cardinal/uterosacral ligaments adjacent to the lateral vaginal apex closure sutures and uterosacral ligament plication sutures. if McCalls duldoplasty is done at time of TVH cysto is recommended
72
urinary tract injury not recognized at time of surgery
present within 2 weeks post op symptoms: anuria or oliguria, hematuria, plan pain, fever, GI symptoms, leakage fo clear fluid do CT scan AP with IV contrast; if not definitive can do cysto with retrograde pyelography; if partial injury found, stent can be placed; if full injury, PCN should be placed; formal repair in 3 months if found <7 days from surgery, primary repair can be done; otherwsie should wait 3 months
73
Needle stick evaluation
immediately clean the area with soap and water and alcohol (virucidal to HIV, HBV, HCV) do serologic tests for HIV HBV and HCV on patient and provider if patient known to have HIV, check recent viral load, antiretroviral treatment history and any history of drug ressitance If HIV status of patient is unknown, can start PEP and stop if HIV is negative PEP should be started within 1-2hrs of needle stick; 3/1000 without ppx is risk of HIV PEP now three drug HAART
74
called to recovery room after TAH BSO for oliguria
ddx: obstruction of foley catheter, misplacement of foley catheter, intravascular volume depletion resulting from preoperative dehydartion or from inadequate intraoperative fluid admin, hemorrhage, obstruction foureters, cystotomy, acute renal disease management: replace foley catheter, complete review of I/Os, urine specific gravity, IVFB 500cc; if no response, consider return to the OR for cysto--bladder integrity and ureteral function; consider passing stents, if normal more likely a fluid balance/renal disease issue
75
septic thrombophlebitis
consider if persistent fever of at least 3-5 days despite antibiotic therapy and no evidence of pelvic abscess ovarin vein thrombophlebitis: acutely ill, fevera nd abdominal apin within one week fo pelvic surgery deep septic pelvic thrombophlebitis; patients present more subtly with fever in first 3-5days postop but apper clinically well antibiotics and anticoagulation are given; optimal duration of anticoagulation is uncertain; can stop 48hrs after resolution of fever; if confirmed vascular thrombosis or hypercoagulable state can continue for 2-6w
76
vaginal bleeding/discharge several weeks after hysterectomy
retained suture or other foreign material not completely re-absorbed granulation tissue reaction at the site of vaginal apex closure entrapment of intraperiotneal tissue at vaginal apex (FT, bowel) tramatic bleeding new neoplastic process retained sponge vaginal apex mass: hematoma, abscess, entrapment of bowel, or adexal structure, urinoma
77
transfusion reactions
simple febrile reaction (aka febrile non-hemolytic transfusion reactions); caued by antibody reaction against the donor leukocytes in the product--manage with antipyretics allergic reactions--allergy to the plasma proteins; give antihistamines anaphylactic reactions hemolytic reactions: recipients antibodies induce hemolysis of donor RBCs; ABO incompatibility--AKI, DIC and hemodynamic collapse occurs; activation of the coagulation system by massive RBC destruction inducing DIC transfusion related acute lung injury (TRALI)--recipient's neutroophils are activated against a transfused product; fever, chills and respiratory distress occurs; blood transfusion should be stopped--the donor is notified so that they don't donate more blood; you can resevied other blood products from other donors
78
periop management of diabetic patient
review of PMH, evaluation of retinopathy, nephropathy, neuropathy, heart disease, peripheral vascular diease and HTN physical exam CBC, chemistry, hepatic/renal function, A1c, ECG and CXR post op risks: healing complications including wound infection and breakdown, hematoma, seroma, dehiscence, ileus/obstruction, infections, thrombotic events, CV event Dm patient should have surgery first thing in AM, routine ionsuling held moring or surgery; can do SSI during surgery or baselien IV insulin infusion at 1u/hr (mandatory for insulin dependent diabetes) type 1 diabetics will always require basal insulin even when not eating
79
periop DVT eval
calculate caprini score for all 1-2 means low risk mechanical ppx enough 5 or greater, pharacologic and mechanical if average risk of bleeding (if high risk hold anticoag until after) stop coumadin 5 days before if less than that, check INR and give vit K and recheck can give PPC to diagnose DVT; assess clinical pretest probability with modified well's score; if low risk get D-dimer; if normal nor further work up, if elevated get doppler US
80
prevention of alchohol withdrawal
benzodiazepines and CIWA protocol starting day of surgery and continued perioope MVI and 100mg thiamine during hospitalization