Gyn dead station CCT

Question 1

Complications of pelvic lymph node dissection

Answer 1

Lymphocele
Lymphedema
Thromboembolic events: DVT/PE
Ureteral injury
Neurologic injury: obturator nerve (sensory aspect of the medial aspect of thigh): enters the pelvis behind the iliac arteries, runs laterally along the pelvic sidewall and exits via the obturator foramen
Vascular injury

Question 2

What is the moa of laparoscopic ovarian drilling in PCOS?

Answer 2

• Similar to ovarian wedge resection –> destroy ovarian androgen producing tissue and reduce the peripheral conversion of androgens to estrogens.
• A fall in the serum levels of androgens and LH and an increase in FSH have been demonstrated after ovarian drilling.
• The endocrine changes following surgery are thought to convert the adverse androgen dominant intrafollicular environment to an estrogenic one, and to restore the hormonal environment to normal by correcting the disturbances of the ovarian pituitary feedback mechanism.
• Thus both local and systemic effects are thought to promote follicular recruitment, maturation and subsequent ovulatino

Question 3

1. Name the instrument on figure (1).
2. Name TWO gynaecological procedures which can be done with the instrument on figure (1).
3. Name the instrument on figure (2).
4. Name TWO surgical procedures which can be done with the instrument on figure (2).
5. Name the instrument on figure (3).
6. Describe how you will use the instrument on figure (3).

Answer 3

1. Cuscos bivalve speculum
2. Cervical smear, endometrial aspiration, large loop excition of transformation zone (LLETZ) of cervix/LEEP (loop electrosurgical excision procedure), cone biopsy
3. Sims speculum
4. Vaginal hysterectomy e.g. prolapse surgery, dilatation and currettage, hysteroscopy, suction and evacuation of uterus
5. Cervex brush
6. Insert the tip of the cervex brush into the cervical os; push gently and rotate 5 times. Rinse brush into the cytology medium by pushing it into the bottom 10 times, force the bristles apart. Swirl the broom vigorously and discard the brush

Question 4

A lady complains of menorrhagia for 6 months, but no other significant menstrual symptoms. Last menstrual period is 6 weeks ago. She also complains of anaemic symptoms, including dizziness and shortness of breath. On physical examination, she has conjunctival pallor, and her uterus is at 16 weeks of size and bulging to one side. Other findings are normal.
1. What is most likely dx
2. Name 2 Ix you will arrange
3. Name 3 medical treatment options
4. Name 2 surgical treatment options
5. Name 3 possible complications during pregnancy
6. What will be the progress of condition in Q1 after menopause?
7. What is the risk of malignancy?

Answer 4

1. Uterine fibroid
2. Blood x CBC, clotting profile, iron profile. USG pelvis. Pregnancy test.
3. Non-hormonal (oral tranexamic acid +/- mefenamic acid (NSAID), hormonal treatment (levonorgestrel releasing IUS if fibroids <3cm with no cavity distortion, combined pills, cyclical oral progestogens (e.g. norethisterone), ferrous sulphate
4. Myomectomy, hysterectomy
5. Miscarriage, red degeneration of fibroid, malpresentation, obstructed labor, postpartum hemorrhage
6. It will regress
7. 0.1-0.2%

Question 5

A pregnant lady received dating ultrasound scan at 12 weeks of gestation. In the ultrasound report, a 12 week single viable fetus was seen, and an anterior subserosal fibroid at the upper uterine wall.
1. Name TWO antenatal complications of uterine fibroids.
At 20 weeks of gestation, the lady was admitted for right lower quadrant pain. Physical examination was normal except tender right lower quadrant mass.
2. What is the likely diagnosis?
3. How will you manage this diagnosis?
4. Name ONE immediate postpartum complication related to fibroids.
5. What is the mechanism of fibroid increasing the risk of this complication?

Answer 5

1. Miscarriage/preterm delivery, red degeneration, malpresentation/abnormal lie, fetal growth restriction
2. Red degeneration of the fibroid
3. Medical treatment by NSAIDs
4. Primary postpartum hemorrhage
5. Fibroids increases risk of postpartum hemorrhage by decreasing both the force and coordination of uterine contractions, therefore leading to uterine atony

Question 6

A pregnant lady comes for antenatal follow-up at 28 weeks of gestation. On physical examination, her symphysiofundal height is measured at 31cm. She also received a growth scan at 27 weeks of gestation. In the ultrasound report, the growth parameters of the fetus are normal, and the amniotic fluid index (AFI) was 12. A uterine fibroid was found incidentally, measuring 8 x 8 x 6 cm.
Her antenatal blood tests were normal, and enjoyed good past health.
Cardiotocography taken at the clinic is normal.

1. What is the main abnormality in physical examination?
2. What is the most likely cause?

Five days later, the patient presents to the A&E department for right lower quadrant pain.
3. What are the differential diagnoses?
4. Name THREE maternal or fetal complications of the condition in Q2.

On follow-up at 36 weeks, the fetus was found to be in breech presentation.
5. Which mode of delivery would you prefer?
6. Name TWO parameters you would look for in cardiotocography.

Answer 6

1. The SFH is large for gestational age
2. Uterine fibroid (causing uterine cavity distortion)
3. Gynaecological: red degeneration of fibroid, pelvic inflammatory disease, ovarian cyst torsion/rupture
   Obstretical: abruptio placentae
   GI: acute appendicitis, acute cholecystitis, acute cholangitis, diverticulitis
   Urinary: urinary tract infection, ureteric stone
4. Miscarriage, red degeneration, malpresentation, obstructed labor, postpartum hemorrhage
5. Elective LSCS or ECV at 37 weeks followed by vaginal delivery if successful
6. Fetal heart rate. Baseline FHR: tachycardia, bradycardia, sinusoidal form. Variability: any loss of variability (alarming), accelerations (normal), decelerations (early deceleration: normal; variable/ late decelerations: alarming!)
   Uterine contractions (Frequency of contractions and to compare to FHR for acceleration/deceleration)

Question 7

Pre-menopausal woman experienced on and off abdominal pain. LMP 6 weeks ago.
USG: 8x6 cm homogenous hypoechoic cyst at right adnexa, right ovary not visualized.
1. What is the first investigation you need to do?
2. Based on the USG finding, what is the most likely diagnosis?
3. What treatment will you offer?
4. Name three complications of the above treatment mentioned

Answer 7

1. Pregnancy test
2. Right endometriotic cyst
3. Laparoscopic ovarian cystectomy
4. Rupture of cyst, wound complications (infection, pain), adhesion formation, bleeding, injury to surrounding organs (bladder, uterus, bowel), uterine perforation

Question 8

Presents with dysmenorrhea, clinical note
USG report attached (provided the features of the cyst, saying it is most compatible with endometriotic cyst)
1. Base on the USG finding, what is the most likely diagnosis?
2. What treatment will you offer?
Pathology report show endometriotic cyst
3. What 2 symptoms other than dysmenorrhea would she experience?
4. What treatment can reduce the risk of recurrence?
COCP x 2 years
Defaulted FU. Come back 2 years later. Dx with hypertension on anti-hypertensive but poor compliance.
5. Name 3 non-surgical Tx for dysmenorrhea

Answer 8

1. Endometriotic cyst (homogenous hypoechoic cyst)
2. Cystectomy using laparoscopy (<10cm)/laparotomy (>10cm)
3. Dyspareunia, pelvic pain, infertility
4. COC pills
5. Simple analgesic: paracetamol, NSAIDs: mefanemic acid, naproxen. DMA or LNG IUG if contraception required.

Question 9

A 30-year-old woman complains of increasing dysmenorrhoea in recent 2 years. On physical examination, a tender mass can be palpated in the right adnexa.
1. What is the most likely dx?
2. What Ix would you order, and what is the expected fingins?
3. What is the treatment?
4. Her friend suffering from the same disease and underwent a surgery. How would you advise her?
5. Name 3 options of medications
6. Name 2 side effects of each medication

Answer 9

1. Right endometriotic cyst
2. Pelvic USG: homogenous hypoechoic mass
3. Cystectomy
4. Complete excision of visible endometriosis brings symptomatic relief in 70-80% of patients.
   Howevere risk of recurrence remains high after surgery.
   However, prophylactic medications are still required to prevent prolapse.
   Invasive lesions e.g. into the colon or rectum, require extensive surgery (e.g. bowel resection by colorectal surgeons).
5. NSAIDs, COC pills (e.g. microgynon), progestogen only pills (Oral dienogest) –> indicated in patients unable to take COCs, GnRH agonists + addback therapy (with estrogen or/and progestogens to reduce AE such as decreased BMD and menopausal symptoms
   6.
   NSAID: peptic ulcer disease, allergic reaction
   COC: minor (nausea, vomiting, dizziness, headache, fluid retention), major (thromboembolic risk, increase CVS risk, increase risk of CA cervix or CA breast
   POP: irregular vaginal bleeding for 6 months; amenorrhea from 6 months onwards
   GnRH agonists: hypoestrogenic SE (those of menopause) e.g. hot flushes, dizziness, palpitation; mood swings, depression/anxiety; decreased libido; vaginal dryness, burning sensation

Question 10

A woman presented with lower abdominal pain for 2 days. Last menstrual period was 3 weeks ago. On examination, her blood pressure was 130/80 mmHg, heart rate 110 per minute, and body temperature 38.5°C. Cervical excitation was positive.

1. What is the most likely diagnosis?
2. Name TWO differential diagnoses.
3. Will you perform a pregnancy test?
4. What treatment will you offer?

Ultrasound was performed for persistent abdominal pain and fever for 2 days. In the report, the ovaries were not visible, and a 4cm cyst and a 5cm cyst were found on left and right adnexae respectively. Some free fluids in the pouch of Douglas were detected.

5. What is the most likely dx?
6. How will you treat the patient?

Answer 10

1. Acute pelvic inflammatory disease (PID)
2. Ectopic pregnancy, ovarian cyst complications, UTI, acute appendicitis
3. Yes as the LMP may not be true menstruation. Her true LMP may be well over 3 weeks ago
4. Inpatient management (clinically severe)
   IV ceftriaxone 2g daily + PO doxycycline 100mg q12h followed by
   PO doxycycline 100mg BD+ PO metronidazole 400mg BD for 14 days
5. Tubo-ovarian abscess
   6.
   Laparoscopy: drainage of abscess and fluid in pouch of douglas, insertion of wide bore drain, irrigate pelvic cavity
   Send sample for C/ST and screen for other STD
   Post op counselling: barrier contraception, contact tracing +/-treatment of partern(s)

Question 11

A G1P0 lady was admitted to A&E department with abdominal pain and PV bleeding. Pregnancy test was positive. Attached vitals indicated hypotension, tachycardia and tachypnoea.
1. What are the abnormal findings?
2. What is the most likely diagnosis?
3. What is your immediate action?
4.What is the treatment option in this scenario?
5. What will be your advice to her?

Answer 11

1. Hypotension, tachycardia and tachypnoea
2. Ruptured ectopic pregnancy
3. Perform resuscitation (ABC), airway and breathing: ensure patient airway, monitor SaO2, O2 supplement if SaO2 low, circulation: monitor BP, HR, urinary output (foley catheterization); fluid resuscitation with colloid+/- crystalloids +/-packed cells
4. Laparotomy and salpingectomy
5. Immediate surgery required to confirm the dx of ruptured ectopic pregnancy and save her life. Her future risk of developing ectopic pregnancy is raised. Does affect fertility (may not affect if other tube patent), contraception methods (if no desire for pregnancy)

Question 12

2 years post left ectopic pregnancy, the woman complains of inability to conceive. Hysterosalpingogram shows a dilated and tortuous right Fallopian tube. Semen analysis of her spouse is normal.
1. How would you explain the results to the patient?
2. What is the cause of subfertility?

Answer 12

1. Since her spouses semen analysis is normal, it is unlikely that his husbamd is the cause of infertility. Hysterosalpingogram shows that her right tube is blocked. Her left tube is most probably resected during the surgery for ruptured ectopic pregnancy. Therefore, the ovum has no route to be fertilized and transferred to the uterus, therefore leading to subfertility.
2. Right tubal blockage and left salpingectomy

Question 13

A G2P0 lady, with previous history of spontaneous complete 1st trimester miscarriage, presented with PV spotting and abdominal pain for 1 day at her 7th week of gestation. USG report attached: Intrauterine sac seen, CRL 9mm (6 week), no fetal heart pulsation, confirmed by 2 radiologists.
1.What is the dx?
2. What are choices of Mx?
Lady has another miscarriage 6 months later.
3. Name 3 Ix to perform
4. If all Ix you performed turned out to be normal, what is the probability of her having a pregnancy next time?

Answer 13

1. Silent miscarriage
2. Expectant, medical (vaginal misoprostol), surgical (evacuation of retained products of gestation)
3. Chromosomal abnormalities (balanced translocation: peripheral blood karyotyping of both partners, karyotyping of placental tissue of abortus.
   Uterine abnormalities: pelvic USG (congenital malformation of uterus, large fibroid)
   Autoimmune causes (APL): blood test for lupus anticoagulant, anticardiolipin antibodies and anti B2 glycoprotein I
   Endocrinological causes (not routinely ordered unless symptomatic): DM (OGTT, HbA1c), hypothyroidism (TFT)
4. 80%

Question 14

A 66 years old woman presented to your clinic complaining of post-menopausal bleeding for a week. Other then bleeding, she had also complained of burning sensation in vaginal/cervix. She had undergone menopause in 55 years old already and this is her first time having post-menopausal bleed. She had good past medical history and had no regular gynaecological check up before.

1. What 3 other important points will you ask in history taking?
   You see this on speculum exam. What is your provisional diagnosis?
2. What three investigations would you do?
   A3. ll investigations come back to be normal. The patient complains of persistent vaginal itchiness and burning sensation. What medications will you prescribe?
3. After the medication, the patient still complains of persistent vaginal spotting. What investigations will you do now?
4. List 3 complications of the investigation.

Answer 14

1. Amount of bleeding, vaginal dryness/dyspareunia, constitutional sx, family history, drug history, surgical history
2. Atrophic vaginitis
3. Endometrial aspiration, cervical smear, USG pelvis
4. Vaginal premarin cream
5. Hysteroscopy and biopsy
6. Bleeding, cervical stenosis, infection

Question 15

1. What is the dx?
2. Name 4 RF for this condition
3. Patient prefers non surgical treatment
4. Name 3 disadv of this treatment
5. The patient opts for surgery now. What is the most common surgery conducted?
6. Patient is worried about recurrence after surgery. What is your advise?

Answer 15

1. 3rd degree pelvic organ prolapse (procidentia)
   2.
   * Weakened pelvic floor: pregnancy related (damage to pelvic muscles and their innervation: multiparity, long 2nd stage of labor, instrumental delivery, episiotomy, macrosomic baby. Menopause, AMA, congenital connective tissue diseases e.g. Marfan, Ehlers Danlos
   * Increased intraabd pressure: obesity, chronic cough/constipation/urinary difficulty, occupational stress (lifting, heavy objects, weightlifters)
   * Lack of suspension: history of hysterectomy –> vault prolapse (as the cardinal and uterosacral ligament is resected)
2. Ring pessary
3. It can only alleviate, but not reverse or cure the symptoms of hte uterine prolapse (need to change every 6 months). It reveals occult stress urinary incontinence, constipation, slippage, increased vaginal discharge, pressure ulcers (especially if women has atrophic vaginitis), vaginal bleeding and infection
4. Vaginal hysterectomy (+/- bilateral salpingooophorectomy) and pelvic floor repair (VHBSOPFR)
5. After surgery there will be a risk of relapse (as high as 30%), additional surgery: sacrocolpopexy, sacrospinous fixation, may be indicated in future vault prolapse. Pelvic floor excercise, RF modification.

Question 16

40 year old clerk presented with vaginal bleeding complicating pregnancy. USG shows uterus enlarged with a large multicystic mass, with a 5cm multicystic mass over the right ovary and a 6 cm mass over the left ovary.
1. What is her dx?
2. What Ix would you do?
3. What treatment would you give?
4. How would you prepare her for the treatment?
5. What can be the complication of her situation?
6. What would you do after her treatment?
7. What advise would you give her before discharge?

Answer 16

1. gestational trophoblastic disease (not neoplasm unless malignant)
2. CBC, LRFT, clotting profile, rhesus status, serum hCG, hPL, pelvic USG (transvaginal)
3. Suction evacuation with currettage
4. Cervical dilatation and priming (hydroscopic cervical dilator, cannot use misoprostol), mechancial dilation of cervix
5. Progression to GTN w/ one cx being metastasis to distant organs. Uterine rupture due to high hCG levels.
6. Serial hCG monitoring for 12 months
7. Advise contraception >1 year (avoid interference with monitoring from new pregnancy), prognosis is good: 95-100% despite high or low risk

Question 17

A 35 y/o lady came to the gynaecological clinic for 3-month history of postcoital bleeding. Her menstruation was regular all along, with normal flow. Her abdominal and pelvic exam were normal.
1. What Ix done at this tage?
2. Ix in Q1 showed abnormal results. She was referred for another Ix to examine the cervix. What is the item shown in the photo used for?
The lady defaulted follow-up for some time, and came back again when the report of investigation in Q2 was available. It showed CIN III and koilocytosis.
3. What is the aetiological agent for the findings?
4. What is the surgical procedure to be done>
5. Apart from bleeding and infection, name 2 other complications of the procedure
6. What will be the Mx plan?

Answer 17

1. Cervical smear for cytology
2. Biopsy forceps for taking cervical biopsy
3. HPV
4. Large loop excision of transformation zone (LLETZ) of cervix
5. Cervical stenosis. Cervical incompetence, leading to increased risk of miscarriage, preterm births and low birthweight babies. Injury to nearby organs e.g. bladder and rectum
6. Repeat cytology every 6 months x 3 times. If all normal: yearly smear x 10 years, then routine screening every 3 years. If LSIL/ASC-US: if persists for 2 consecutive times (1 year) refer colposcopy. If HSIL/ASC-H: refer colposcopy
   Opt for cotesting (HPV and cytology) in 12 months x 2 times (2 years)
   If both normal: cotesting x 3 years, then routine screening
   Either HPV or cytology (persistent ASCUS,LSIL,HSIL) abnormal in any circumstance: refer colposcopy

Question 18

A woman was found to have high-grade squamous intraepithelial lesion (HSIL) on cervical cytology.
1. Name ONE investigation you will arrange for this woman.
2. Describe the procedures in the investigation above.
3. The patient defaulted follow-up, and presented with abnormal vaginal bleeding 10 years later.

Answer 18

1. Colposcopy
2. Patient lies in lithotomy position, and her perineum is exposed.
   A speculum is inserted into her vagina. A colposcope is used to magnify the cervix.
   The cervix is firstly cleaned with normal saline. 5% acetic acid is added to detect any acetowhite areas. Lugols iodine added afterwards to delinate the squamocolumnar junction. Cervical biopsy can be taken at this juncture by a pair of biopsy forceps, and haemostasis is achieved by ferrous sulphate. If women has high grade lesion (HSIL, ASC-H), large loop excision of transformation zone (LLETZ) can be performed under local anesthesia (lignocaine + adrenaline)
3. Cervical cancer

Question 19

1. What will you do to confirm the diagnosis?
   The diagnosis is confirmed to be squamous cell carcinoma of cervix.
2. Name TWO further investigations you will arrange.
3. What surgery will you offer her?
4. Name THREE long-term complications of the operation.
5. If she does not want oophorectomy, would you allow her to preserve her ovaries?

Answer 19

1. Punch biopsy of the cervical lesion
2. Blood test: tumor marker (SCC antigen), CBC, L/RFT. Contrast MRI abd and pelvis. Pre op workup: ECG, CXR, clotting profile. Renal tract imaging: USG, IVU, CTU (screen for met)
3. Wertheims/radical hysterectomy (resection of uterus, upper vagina, parametria and lymph nodes)
4. Injury to nearby organs (rectum, bladder, ureters, iliac vessels, obturator nerve), chronic bowel and bladder dysfunction (due to damage of parasympathetic nerves), bowel complications: constipation, IO, adhesions, fistula. LN ectomy cx: lymphedema, lymphocyst, lymphangitis, lymphorrhea.
   Vaginal dehiscence, shortened vagina
5. Yes

Question 20

1. What is the instrument on the photo called?
2. What are the risks of using this instrument?
3. Name TWO other investigations you would arrange.
4. How will you manage the pathology shown in endometrial aspiration?
5. What are the risks of the management method?

Answer 20

1. Pipelle endometrial sampler
2. Uterine perforation, excessive per vaginal bleeding, ascending infection
3. Hysteroscopy, USG pelvis
4. Hysteroscopic polypectomy
5. Uterine perforation, injury to nearby organs (bladder, rectum), fluid overload/electrolyte disturbance (due to glycine for conduction of diathermy), pelvic infection (endomyometritis), intrauterine adhesion, intraop uterine hemorrhage

Question 21

1. Which of the following instrument will you use for investigation?
2. Name the object you choose in Q1, and explain why it is used.
   Result of the investigation showed endometrial hyperplasia.
3. Name FOUR risk factors of this condition in this patient.
4. What is the pathology most likely associated?
5. What subsequent treatment will you advise?
6. If patient declines the option in Q3, name TWO other options.
   The patient agrees for the option in Q3.
   Histology showed endometrial cancer (stage 1A, grade 1 endometrioid cells).
7. What will be your management?

Answer 21

1. Figure one
2. Pipelle endometrial aspirator, for its higher successful rate to obtain adequate sample in premenopausal women. Figure 2: endocervical brush for pap smear
3. Nulliparity, long menstruation cycles (infrequent menstrual bleeding), early menarche, obesity and DM
4. Endometrial cancer
5. Total hysterectomy
6. Hysteroscopy and D&C to rule out endometrial cancer. Oral progestins (medroxyprogesterone), Mirena (progesterone releasing IUCD)
7. TAHBSO and peritoneal cytology. FU with history taking for abnormal vaginal bleeding and PV examination for suspicious lesions.
   FU every 3 months for 2 years –> FU every 6 months for 3-5 years –> FU every year for 5-10 years.

Question 22

A report of endometrial curettage showed complex hyperplasia with atypia. The patient has had a history of endometrial polyp.
1. Name ONE surgical and TWO medical treatment options.
2. Which one do you prefer?
3. The patient opts for surgical treatment. What should you do on follow-up?
4. Among the 2 medical treatment, which one is better?
5. The patient opts for medical treatment. What should you do on follow-up?

Answer 22

1. Surgical: total hysterectomy (+/- bilateral salpingooophorectomy is postmenopausal)
   Medical: progesterone releasing IUCD (Mirena), oral progestins (e.g. medroxyprogesterone, megestrol)
2. Total hysteretomy, for there is high risk of coexistent endometrial cancer
3. History taking for abnormal vaginal bleeding, abd pain, distension from vaginal and peritoneal metastasis. Speculum exam for suspicious lesions. Check blood for CA125 if raised preop.
4. Mirea, for higher local effect and effectiveness
5. For atypica cases: surveillance q3 months with endometrial aspirate until 2 consecutive negative aspirates, then follow every 6-12 months until hysterectomy done.

Question 23

A 68-year old woman presented with her first episode of post-menopausal bleeding. Endometrial sampling was attempted but failed because the cervical os was too tight. Ultrasound scans of the pelvis (transabdominal & transvaginal scans) were done, with the report indicating the endometrial thickness was 1.2 cm.

1. What is the cut-off of endometrial thickness in postmenopausal women?
2. Name THREE potential complications of hysteroscopy
   A diagnostic hysteroscopy and curettage was subsequently arranged, with pathology showed grade 1 endometrioid adenocarcinoma. The complete blood count, liver and renal function tests were normal.
3. Name TWO other investigations you would like to perform.
4. Name TWO risk factors of endometrioid adenocarcinoma in general.
5. What is the management of her condition?

Answer 23

1. 4mm
2. Bleeding (post hysteroscopy vaginal bleeing), perforation of uterus/bladder, requiring additional surgery. Infection: endomyometritis, fluid overload, bladder/bowe injury
3. Pelvic MRI: locoregional staging, myometrial invasion, invasion to surrounding structures. CXR, CT A+P, PETCT for met, CA125 as baseline
4. Advanced age
   Related to estrogen exposure: obesity and DM (fat converting androgens to estrogen), PCOS, early menarche, late menopause, nulliparity, unopposed estrogen HRT, tamoxifen, Lynch syndrome
5. Total abd hysterectomy, bilateral salpingooophorectomy + lymph node dissection (depends on staging/ could be debulk surgery in which LN dissection not done)

Question 24

1. What features will you look for in ultrasound of the uterus for this patient? Name TWO.
2. What is the diagnosis?
3. Name TWO procedures which can be performed during hysteroscopy.
4. If glycine is used to distend the uterine cavity, name ONE post-operative risk which needs to be looked out for.
5. Besides the complication in Q4, name FOUR additional risks of hysteroscopy.
   During hysteroscopic polypectomy (under GA), the omentum can be seen, and there is profuse bleeding.
6. What would be your management?

Answer 24

1. Thickened endometrial lining (>4mm), any obvious growth from endometrium
2. Endometrial polyp
3. Hysteroscopic polypectomy, hysteroscopic myomectomy
4. Hyponatremia (TUR syndrome: absorption of electrolyte free irrigating fluid)
5. Bleeding (post hysteroscopy vaginal bleeding), perforation of uterus/bladder, requiring additional surgery. Infection: endomyometritis. Fluid overload, bladder, bowel injury
6. This is uterine perforation. Acute Mx: resuscitation, airway and breathing: ensure patent airway, monitor SaO2. circulation: monitor BP, HR, urinary output (with foley catheterization). Cal senior gynaecologist, general surgeon and anaesthetist. Book OT for emergency repair to repair uterine perforation.

Question 25

1. Calculate the risk of malignancy index for this lady.
2. Name TWO additional investigations you will arrange for her.
3. What surgery will you offer to her?
4. The patient asked whether the surgery could be done laparoscopically. Give your advice (1@) and the reason supportive your advice
5. What is the most likely histology?
6. What adjuvant therapy would you recommend?

Answer 25

1. Ultrasound score (4 malignant features) = 3, menopausal score =3, CA125=200. RMI = 200 x 3 x 3 =1800, indicating high risk of cancer (>250)
2. CT/MRI abd + pelvis to assess distant metastasis. CXR to assess lung metastases/ pleural effusion. Peritoneal tap cytology to detect malignant cells.
3. Total abd hysterectomy and bilateral salpingo-oophorectomy, pelvic + paraaortic lymphadenectomy and surgical staging
4. No because surgery is required to stage the disease and extensive resection (including THBSO, lymphadenectomy, omentectomy, peritoneal debulking, peritoneal lavage) is not feasible in laparoscopic surgery. The abd organs need to be palpated by the hands ot surgeon to detect metastasis.
5. High grade serous epithelial carcinoma
6. Adjuvant chemotherapy (carboplatin +paclitaxel)

Question 26

1. What is most likely dx?
2. Calculate RMI of this lady
3. Name 2 Ix you will arrange
4. What surgery to offer
5. Name 4 complications of this surery

Answer 26

1. Ovarian carcinoma
2. USG score (3 malignant features) = 3, meneopausal score = 3, CA125= 400, therefore RMI = 3x3x400 = 3600 (high risk of cancer)
3. CT/MRI abdomen and pelvis to assess distant metastasis. CXR to assess lung metastasis/pleural effusion. Peritoneal tap cytology to detect malignant cells
4. Total abd hysterectomym and bilateral salpingoophorectomy (TAH BSO), pelvic and paraaortic lymphadenectomy and surgical staging
5. Pelvic haematoma and bleeding, pelvic infection, injury to adjacent organs, including bowels, bladder and ureters. Post op urinary and bowel dysfunction, vault prolapse. Internal scarring and adhesions, Lymphedema due to pelvic and paraaortic LN (if high grade carcinoma) dissection as part of staging. For premenopausal: iatronigec menopause and infertility

Question 27

1. What is the contraception method called?
2. Name 3 contraindications
3. A lady came in some time later after the insertion of the instrument. On speculum examination, the thread of the instrument is missing. Name TWO possible causes.
4. What investigation will you arrange and what advice will you give her?

Answer 27

1. Intrauterine contraceptive device (IUCD)
2. Known/suspected pregnancy, current genital tract infection (pelvic inflammatory disease), undiagnosed vaginal bleeding, lesions distorting endometrial cavity e.g. large fibroids. Large uterus, defined by >10cm by uterine sound. Congenital malformations of the female genital tract. GTN.
3. IUCD in situ, unrecognized IUCD expulsion, IUCD perforation into peritoneal cavity
4. USG uterus +/- AXR and KUB
   USG uterus: if IUCD in situ –> leave it alone; if IUCD absent –> AXR and KUB
   AXR and KUB: if IUCD present in peritoneal cavity –> arrange elective laparoscopy; if IUCD absent –> can presume it has been dislodged
   Advise: on the need of additional contraception, since we cannot confirm whether the IUCD is still in the uterus. Come back to A&E department immediately if severe abd pain or PV bleeding.

Question 28

A 35-year-old lady, who has completed her family, is currently taking combined oral contraceptive pills after the birth of her second child. She heard from her friends that she should stop taking pills at this age. She wants to know more about female sterilisation.

1. Does she need to stop her oral contraceptive pills? Why?
2. Name 3 disadv of tubal occlusion
3. Name the 3 below methods of contraception
4. Later, she has undergone female sterilisation, divorced and remarried. She is planning to get pregnant now.
   What could be done to get her pregnant again?

Answer 28

1. No. COCP can be continued up to age of 50 if no other contraindication arises until then
2. Irreversibility: it is permanent. Risk of failure due to recanalization, increase chance of ectopic pregnancy in future. Surgical risk associated with laparoscopy, mini-laparotomy and general anesthesia i.e. bleeding, wound complications, visceral damage
3. Reversal of tubal ligation, IVF

Question 29

1. What is the device shown in figure (1)?
2. Name 3 contraindications of this contraceptive method.
3. Name 2 pieces of advise you will give to Ms Wong if it is used
4. What is the device shown in figure 2
5. What additional method does this contraceptive method offer?
6. Ms Wong comes back 3 months later and is upset because of a side effect of this contraceptive method.
   Name ONE common side effect.

Answer 29

1. Copper IUCD
2. Known/suspected ectopic pregnancy, current genital tract infection (pelvic inflammatory disease), undiagnosed vaginal bleeding, lesions distorting endometrial cavity e.g. large submucosal fibroid. Congenital malformations of the female genital tract. Gestational trophoblastic neoplasia/
3. Should come back for FU 6 weeks later, followed by annual follow up for check up. Copper IUCD can be used for 3-10 years. It can be easily removed by a simple, out patient procedure.
   Adv: highly affective, immediately active after insertion, long acting and reversible
   Disadv: copper IUCD can cause menorrhagia and/or dysmenorrhea and increased vaginal discharge
4. Mirena (levonorgestrel IUCD)
5. It alleviates menorrhagia and dysmenorrhea
6. Prolonged spotting for 3-6 months