GYN

Question 1

Minimum evaluation of complaint of urinary incontinence

Answer 1

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)

Question 2

UUI tx

Answer 2

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

Question 3

behavioral for UUI and/or SUI

Answer 3

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

Question 4

surgical for UUI and/or SUI

Answer 4

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

Question 5

simple fistulectomy procedure

Answer 5

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

Question 6

treatment of ectopic pregnancy

Answer 6

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

Question 7

contraindications to MTX for ectopic

Answer 7

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

Question 8

Dosage MTX for ectopic

Answer 8

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

Question 9

heterophile hcg

Answer 9

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

serum levels usually <1000

Question 10

CREST tubal ligation failure reates

Answer 10

(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

Question 11

most common complication after GYN surgery

Answer 11

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

Question 12

surgical procedures requiring abx ppx

Answer 12

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)

Question 13

urovaginal fistula work up

Answer 13

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)

Question 14

medical management of fibroids

Answer 14

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

Question 15

complications of UAE

Answer 15

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

Question 16

non ovarian cancer causes of elevated CA-125

Answer 16

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

Question 17

gonorrhea treatment

Answer 17

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

Question 18

AUB

PALM-COEIN

Answer 18

Polyps
Adenomyosis
Leiomyoma
Malignancy

Coagulopathy
Ovulatory dysfunction
Iatrogenic
Not otherwise specified

EMB >45; younger if RF

Question 19

benign breast lesions

Answer 19

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

Question 20

work up of a breast mass

Answer 20

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%

Question 21

most common cuase of bloody nipple discharge

Answer 21

benign intraductal papilloma

Question 22

most common cause for a solid breast mass

Answer 22

fibroadenoma

Question 23

Breast MRI indicated

Answer 23

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

Question 24

complete v partial mole

Answer 24

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

Question 25

concern for post molar GTN

Answer 25

increasing hCG>10% accross 3 values over a 2 week period
plateauing hCG: 4 measurements that remain within 10% over at least 3 weeks

Question 26

GTN

Answer 26

invasive mole
choriocarcinoma
PSTT
epithelioid trohpoblastic tumor

Question 27

FIGO and GTN

Answer 27

age
duration from antecedent pregnancy
type of pregnancy
pre treatment hcg
largest tumor size
site of mets
number of mets
history of failed chemo

Question 27

most common causes of cancer death in women

Answer 27

lung
breast
colon
pancreas
ovary

Question 27

histopathology of lichen sclerosis

Answer 27

loss of rete pegs, thinned epidermins, hyperkeratosis

Question 27

histopathology of papillary hidradenoma

Answer 27

appears malignant under low poer but benign on high power

Question 28

histopathology of condyloma

Answer 28

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

Question 28

histopathology of dysgerminoma

Answer 28

lymphocyte infiltrated stroma (large vesicular cells with clear cytoplasm that resember fried eggs)

Question 28

histopathology of krukenburg tumor

Answer 28

signet ring cells

Question 29

coffee bean nublei

Answer 29

brenner tumor and granulosa cell tumor

Question 30

langhans giant cell

Answer 30

multinucleated gian cell with nuclei arranged along periphery of cell with opening at one end (horse appearance)

pathognomonic for TB

Question 31

schiller duval bodies

Answer 31

endodermal sinus tumor

Question 31

call exner bodies

Answer 31

granulosa

Question 32

psammoma bodies

Answer 32

LMP; nuclear atypica and cellular proliferation, invasive if breaches basement membrane

Question 32

heavy menstrual bleeding and enlarged irregular uterus. what is ddx.

Answer 32

pregnancy
pregnancy complications
myomas
adenomyosis
adhesion disease giving impression of enlarged uterus
adnexal mass rather than uterine mass
uterine malignancy

Question 32

complications of UAE

Answer 32

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

Question 33

treatment options for symptomatic myoma

Answer 33

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

Question 33

characteristics of a normal period

Answer 33

every 21-35 days; <80cc in blood loss volume

Question 34

quick facts of sacrospinous ligament fixation

Answer 34

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

Question 35

quick facts on uterosacral ligament suspension

Answer 35

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

Question 36

sacral colpopexy

Answer 36

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

Question 37

complication of SUI procedures

Answer 37

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

Question 38

5 compartments to evaluate for pelvic organ prolapse

Answer 38

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

Question 39

indications for inpatient management of PID

Answer 39

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

Question 40

painful bladder syndrome

Answer 40

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

Question 41

ddx of heavy menstrual bleeding and enlarged uterus

Answer 41

pregnancy including mole
myomatous infiltration of the uterus
adenomyosis
adhesive disease giving impression of uterine enlargement
adnexal mass
uterine malignancy

Question 42

ddx for AUB-H

Answer 42

endocrinopathy
oligo-ovulation or anovulation
coagulopathy
adenomyosis
endometrial lesion
cervical lesion

PALM COEIN

Question 43

contraindications to endometrial ablation

Answer 43

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)

Question 44

abx for infected sling mesh

Answer 44

mesh removal
cipro or levo and flagyl x7 days

Question 45

bleeding from TVT

Answer 45

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

Question 46

important complications of sling

Answer 46

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

Question 47

what should every stage III or greater prolapse have checked

Answer 47

PVR for urinary retention ; PVR >100 can be suggestive of voiding dysfunction or detrusor weakness

Question 48

chronic urinary retention

Answer 48

think CVA, MS, DM…or prolapse

management: pessary or surgery for pelvic organ prolapse; evaluate for occult SUI prior to surgery

Question 49

when does peritoneum re-epithelialize?

Answer 49

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

Question 50

suture review

Answer 50

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

Question 51

fascial dehiscence what do you do

Answer 51

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

Question 52

you think you perf during a suction D&C, what do you do

Answer 52

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

Question 53

16yo with saddle injury and blue mass at vulva

Answer 53

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

Question 54

energy in surgery

Answer 54

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

Question 55

Novasure

Answer 55

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

Question 56

TOA and PID

Answer 56

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

Question 57

watery discharge after surgery, what is ddx?

Answer 57

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

Question 58

rectovaginal fistula

Answer 58

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

Question 59

hysteroscopy

Answer 59

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

Question 60

ddx adnexal mass

Answer 60

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

Question 61

pelvic mass in pregnancy

Answer 61

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

Question 62

age specific considerations of solid adnexal mass

Answer 62

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

Question 63

patient risk factors for adnexal mass malignancy

Answer 63

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

Question 64

Ectopic pregnancy

Answer 64

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

Question 65

pregnancy test positive; enlarged bluish cervix

Answer 65

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

Question 66

cornual ectopic

Answer 66

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

Question 67

8w pregnant; 14w size uterus what is ddx

Answer 67

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

Question 68

EIN tx

Answer 68

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%

Question 69

Nerve injuries

Answer 69

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

Question 70

bladder injury repair

Answer 70

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

Question 71

places where ureteral injury can occur

Answer 71

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

Question 72

urinary tract injury not recognized at time of surgery

Answer 72

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

Question 73

Needle stick evaluation

Answer 73

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

Question 74

called to recovery room after TAH BSO for oliguria

Answer 74

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

Question 75

septic thrombophlebitis

Answer 75

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

Question 76

vaginal bleeding/discharge several weeks after hysterectomy

Answer 76

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

Question 77

transfusion reactions

Answer 77

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

Question 78

periop management of diabetic patient

Answer 78

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

Question 79

periop DVT eval

Answer 79

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

Question 80

prevention of alchohol withdrawal

Answer 80

benzodiazepines and CIWA protocol starting day of surgery and continued perioope
MVI and 100mg thiamine during hospitalization