Gynae

Question 1

Ovarian Torsion

Answer 1

• Any age, including infants (usually reprod age)
• Risk factors:
  –> Pregnancy
  –> IVF
  –> Cyst or mass
• History and examination are variable, and not partic. reliable
• Feel for adnexal mass

ULTRASOUND
- Not definitive
- Normal flow does not rule out (60% have N flow)
–> Ovary >4cm -most common
–> Ovary near midline
–> “String of Pearls (peripheral cysts from engorgement)
–> Cyst, mass, free fluid

….if in doubt, CT more sensitive. Or, exploratory lap.

OT ASAP.

Question 2

Ovarian Hyperstimulation Syndrome

Answer 2

Usually 1 week post injections
Most cases mild

CYSTIC ENLARGEMENT OF OVARIES
- Abdo pain, bloating, N&V
- Torsion, haemorrhagic cysts –> peritonism

MASSIVE THIRD SPACING
- Ascites, APO, pleural/ pericardial effusion
–> Hypovolaemic shock

+ Thrombosis
+ Fever

Management is SUPPORTIVE as condition is self-limiting:
- Fluid resus
- Electrolyte correction
- VTE prophylaxis
- Empiric ABx (cef + met)

Question 3

DDx for female pelvic pain:

Answer 3

Consider CYCLIC vs NON CYCLIC

CYCLIC:
- Mittelschmertz
- Endometriosis
- Adenomysis
- Dysmenorrhoea

Question 4

Pelvic Inflammatory Disease: features and diagnosis:

Answer 4

ORGANISMS
SEXUALLY ACQUIRED
Often polymicrobial:
- Chlamydia
- Gono
- Ureaplasma/ mycoplasma
vs
NON-SEXUALLY ACQUIRED (TOP/D&C/IUD)

COMPLICATIONS
- Tuboovarian abcess
- Adhesions
- Infertility (tubal)
- Ectopic pregnancy
- Chronic pelvic pain
- Sepsis

CLINICAL
Varied, can be non-specific:
- Cervical motion tenderness
- Dyspareunia
- Adnexal tenderness/ mass

DIAGNOSIS
- Urine dip (DDx)
- Pregnancy test
- First pass urine for Chlamydia
- High vaginal swab for Gono, others.

Question 5

Treatment for SEXUALLY ACQUIRED PID:

Answer 5

• Ceftriaxone 500mg IM
  + Metronidazole 400mg PO BD for 2weeks
  + Doxycycline 100mg PO BD for 2weeks
  –> Swap for ROXI if preg/BFing
  –> Azithro if IV

IUD can stay in.
Contact trace.

Question 6

Treatment for NON-sexually ACQUIRED PID:

Answer 6

Doxycycline 100mg PO BD for 2weeks alone

or
Augmentin

Question 7

Assessment of sexual assault victim:

Answer 7

Ideally by specific SAS service/personnel.

Gain consent for each step:
- MEDICAL exam
- FORENSIC exam + sampling
- Handover of info/ samples to police

If drunk, must wait.

• History:
  –> Assailant, circumstances, physical events, actions following
• Assess for intoxication/ impaired capacity (ie. ability to consent)
• Forensic Examination:
  1- Undress over dropsheet (to collect hair etc. that may fall off clothing). Store in paper bags.
  2- Inspect for injuries
  –> General
  –> Genital
  –> Use body chart, medical descriptions
  3- Collect samples
  –> Swabs of vagina, endocervix, anus, throat
  –> Fingernail clippings
  –> Urine
  –> Bloods

Screen for:
- Presence of DNA materal (sperm, semen, hair, skin)
- Tox
- Chlamydia/ gono/ trichomonas
- HIV/ syphilis/ Hep C

Offer:
- STI prophylaxis:
–> Ceftriaxone 250mg IM + 1g azithromycin PO + Metronizadole 2g
- Hep B prophylaxis
–> Hep B vaccine
–> + immunoglob if high risk
- HIV prophylaxis
–> Up to 72 hours
- Pregnancy prophylaxis
–> 1.5g levonorgestrol ASAP (up to 5d)
- Psychological support

Question 8

‘Sexual assault’ vs ‘Sexual abuse’

Answer 8

Sexual assault: act of a sexual nature carried out against the will of the victim. Consent is not given, or not given freely.

Sexual abuse: When consent would not be valid, even if freely given (ie. intellectually impaired with carer, child <15-17 with adult etc.)

Question 9

Post-coital contraception options:

Answer 9

‘Morning after Pill’
- Levenorgestrol *up to 3 days post
- Ulepristal acetate up to 5 days

Copper IUD
- 99% effective
- Insert *up to 5 days post

–> Assess for pregnancy first
–> Assess for STI pre-IUD

Question 10

Management of dysfunctional uterine bleeding:

Answer 10

Tranexamic acid

NSAIDs (incl. mefenamic acid)

Contraceptives:
COMBINED:
-. COCP (oestogen + protestogen)
PROGESTOGEN-ONLY
- Mini-pill (levenorgestrel, northindrone)
- Mirena IUD (levenorgestrel)

Surgical:
- Endometrial ablation
- Hysterectomy

Question 11

Causes of DUB:

Answer 11

ENSURE NOT PREGNANT

LESIONS:
- FIbroids
- Polyps
- Endometrial Ca
- Cervical Ca
- Adenomyosis

TRAUMA
- Incl. sexual assault

BLEEDING DIASTHESES
- Incl meds

HORMONAL
- Hypothyroid
- Peripubertal, perimenopausal
- Anorexia nervosa

OTHER
- Vaginal atrophy
- Extreme weight change

Question 12

When in the cycle does Mittelschmerz occur?

Answer 12

At ovulation
Mid-cycle
14 days before due, or 14 days since LMP