Gynae 2 Flashcards
What is an ectopic pregnancy?
Implantation of a fertilised ovum outside the body of the uterus
Where do ectopic pregnancies mostly occur?
Where are some rarer sites of implantation?
97% are in the Fallopian tubes - mostly ampulla or isthmus portions
Rarer sites:
- Cervix
- Ovary
- Peritoneal cavity
- Previous CS scars
What are 3 possible consequences of the implantation of a gestational sac in the Fallopian tube?
1) Extrusion (tubal abortion) into the peritoneal cavity
2) Spontaneous involution of pregnancy
3) Rupture through the tube causing pain and bleeding
Where is it particularly dangerous for an ectopic pregnancy to be located? Why?
The uterine horn - pregnancy may reach 10-14 weeks before rupture
Which ectopic pregnancies can proceed almost to term?
Intraperitoneal pregnancies
List some risk factors for ectopic pregnancy
1) Hx of infertility or assisted conception (esp IVF)
2) Hx of PID
3) Endometriosis
4) Pelvic or tubal surgery
5) Previous ectopic (recurrence risk 10-20%)
6) IUCD in situ
7) POP = does not cause an ectopic pregnancy but if a woman conceives whilst using it, the pregnancy is more likely to be ectopic as progesterone decreases tubal motility
NB anything that slows the ovum’s passage to the uterus is a predisposing factor
What are some symptoms of an ectopic pregnancy?
Always think ectopic in a sexually active woman with abdominal pain, bleeding, fainting or diarrhoea + vomiting!!!
- Often asymptomatic
- Amenorrhoea (typically 6-8 weeks gestation)
- Pain = lower abdo, often mild and vague, classically unilateral
- Vaginal bleeding - starts after onset of pain; often small amount and brown
- Diarrhoea and vomiting
- Shoulder tip pain = diaphragmatic irritation of intra-abdo blood
- Collapse = if ruptures
What are some signs of an ectopic pregnancy? (5)
Vaginal + speculum examinations do not rupture ectopic pregnancies!
Often no specific signs
- Uterus usually normal size
- Abdominal tenderness +/- peritonism due to haemoperitoneum if ruptured
- Cervical motion tenderness occasionally due to stretching of inflamed tissues
- Unilateral adnexal tenderness
What is the very first investigation to do in a patient with ? ectopic ?
Pregnancy test - a negative test excludes an ectopic
What are the strict criteria for expectant and medical management of a diagnosed ectopic pregnancy ?
- Clinically stable
- Asymptomatic and no pain
- hCG < 1000 for expectant; <3000 for medical
- Size < 30mm
- No fetal heartbeat
- No rupture/haemoperitoneum
- Live in close proximity to hospital and have support at home
- Pt deemed reliable to return for follow up
What is the expectant management of an ectopic pregnancy?
- With an already low and falling hCG and fulfilling the required strict criteria
- Take hCG level, which takes a day to process then repeat 48 hours later and if it has fallen significantly, can continue with continue with expectant management
- Repeat serum hCG every 48hrs until repeated fall in level, then weekly until <15IU
(basically the body is expelling it anyway you let it continue)
What is the medical management of an ectopic pregnancy?
Methotrexate IM single dose 50mg/m2
hCG levels should be measured at 4 and 7 days and another dose of methotrexate given (up to 25% of cases) if the fall in hCG is <15% on days 4-7
Sexual intercourse should be avoided during treatment and reliable contraception used for 3 months as methotrexate = teratogenic
SE = conjunctivitis, stomatitis, GI upset - stomach pain may be difficult to differentiate from pain of rupturing an ectopic
When should an ectopic pregnancy be managed surgically?
Surgery should be offered to those women who cannot return for follow-up after methotrexate or if they have:
- Severe pain
- Size >35mm
- Ruptured
- Foetal heartbeat visible on scan
- Serum hCG >5000 IU/L
What is the surgical management that is preferred for an ectopic pregnancy and why? What medication should be given?
Laparoscopy preferred vs laparotomy:
- Shorter operating time and hospital stay
- Less analgesia requirements
- Less blood loss
In haemodynamically unstable patients, laparotomy is more appropriate as quicker
Anti-D should be given to all rhesus negative women who have a surgical procedure to remove an ectopic pregnancy
What is the treatment of an ectopic pregnancy if haemodynamically unstable?
Resuscitation:
- 2 large bore IV lines and IV fluids
- Cross match 6 units of blood
- Call senior help and anaesthetic assistance urgently
Surgery:
- Laparotomy with salpingectomy once the patient has been resuscitated
What can happen if an ectopic pregnancy is not correctly treated?
Tubal or uterine rupture (depending on location of pregnancy), which can lead to massive haemorrhage, shock, DIC and death
What do molar pregnancies arise from?
Molar pregnancies arise from an abnormality in the chromosomal number during fertilisation
The placenta is made of millions of cells called trophoblasts
In trophoblastic disease - abnormal overgrowth of all / part of the placenta causing what is called a molar pregnancy or hydatidiform mole
What is a hydatidiform mole?
Hydatidifom mole = the commonest kind of trophoblastic disease
It is a pre-malignant condition i.e. it is not cancerous but could become malignant
It includes partial moles and complete moles
Are there good cure rates of GTD? Why?
Excellent cure rates
- Central registration and monitoring in UK
- Use of beta-hCG as a biomarker
- Development of effective treatments
What is the classification of GTD?
Premalignant = hydatidiform mole
- Complete hydatifiform mole
- Partial hydatidiform mole
Malignant = GTN
- Invasive mole
- Choriocarcinoma
- Placental site trophoblastic tumour
- Epithelioid trophoblastic tumour
What is the pathophysiology of a complete molar pregnancy?
All the genetic material comes from the father
An empty oocyte lacking maternal genes is fertilised by one sperm, which duplicates so there are 46 chromosomes of paternal origin
The whole placenta is abnormal and usually grows very quickly
There is no developing foetus in these pregnancies
Can also occur when an empty ovum is fertilised by two sperm - causes foetal karyotypes: 46XX, 46XY, (46YY - not viable)
What is the pathophysiology of a partial molar pregnancy?
One ovum with 23 chromosomes is fertilised by two sperm, each with 23 chromosomes so there are 69 chromosomes in the cells (triploidy)
Instead of forming twins an abnormal fetus forms - not viable outside womb
Part of an apparently normal placenta overgrows (proliferates) and part develops normally
69 XXX, XXY, XXY
What is an invasive mole?
Develops from a complete mole and invades the myometrium
What is a choriocarcinoma?
Malignancy of trophoblastic cells
Most often follows a molar pregnancy but can follow a normal pregnancy, ectopic pregnancy or abortion
What are placental site trophoblastic tumours?
Malignancy of intermediate trophoblasts (they normally anchor the placenta to the uterus)
Most often follows a normal pregnancy, but can arise from molar pregnancies or miscarriage
What are some risk factors for molar pregnancies? (6)
1) Aged >45yr or <16yr (extremes of maternal age)
2) Multiple pregnancy
3) Previous miscarriage
4) Light menstruation
5) OCP
6) East Asian ethnicity
How does gestational trophoblastic disease present?
Irregular vaginal bleeding in the first trimester (>90%)
Abdominal pain - large theca lutein cysts resulting from ovarian hyperstimulation from high hCG
Uterus size greater than normal for gestational age
Passage of vesicles (like bunch of grapes) through vagina
Endocrine symptoms due to high hCG levels - hyperemesis gravidarum, pre-eclampsia, hyperthyroidism
Why should women who have persistent abnormal vaginal bleeding after a non-molar pregnancy undergo a pregnancy test?
To exclude persistent GTN
It should also be considered in any woman developing acute respiratory or neurological symptoms after any pregnancy
What is the first line investigation for GTN?
beta-hCG: urine and blood levels
- A urine pregnancy test should be performed in all cases of persistent or irregular vaginal bleeding after a pregnancy event
- Trophoblastic tissues secrete hCG, so serum levels are higher than expected for gestational age
What is the FIGO staging for GTD? (I-IV)
Stage I - confined to uterus
Stage II - extends outside the uterus but is limited to genital structures eg adnexa, vagina, broad ligament
Stage III - extends to the lungs with or without genital tract involvement
Stage IV - all other metastatic sites
What is the management of hydatidiform moles?
Dilatation and suction curettage (surgical evacuation) to remove risk of invasion or development into choriocarcioma
Urine PT 3 weeks post-treatment
Follow up at 6 months if urine hCG levels return to normal within 8wks, 2 years if not
Anti-D prophylaxis if mother Rhesus negative
If hCG levels rise, plateau or are still abnormal 6 months after surgical evacuation, chemo is started:
- Methotrexate and folinic acid
- Survival 94%
How many molar pregnancies do not spontaneously regress?
3% - so require chemo
This is more common with complete than partial moles
What are uterine fibroids?
Benign tumours of uterine smooth muscle (myometrium) - also called leiomyomata and myomas
How common are uterine fibroids?
Most common non-cancerous tumours in women of childbearing age - occurring in 77% women
What are some risk factors for developing uterine fibroids?
- Increased lifetime exposure to oestrogen = obesity and early menarche
(protective = exercise and inc parity, also ?smoking) - Afro-American ethnicity (3x more common than white American, also tend to present younger with worse symptoms)
- FHx
NB similar genetics to keloids which also more prevalent in African-American women
List the types of fibroids by their location
Submucosal = >50% bulging into endometrial cavity
Intramural = located within the myometrium
Subserosal = >50% fibroid mass extends outside the uterine contours (under the visceral peritoneum)
Cervical = near cervix
Parasitic = have become detached from uterus and attached to other structures
Which is the most common types of fibroid?
Intramural
What is the pathophysiology of fibroids?
Start as multiple, single-cell seedlings distributed throughout the uterine wall. They increase in size very slowly over many years, stimulated by oestrogen and progestogens
As the fibroid grows, the central areas may not receive adequate blood supply and so degenerate
What are the symptoms of uterine fibroids? (5)
50% asymptomatic
1) Menorrhagia - heavy and prolonged periods (less associated with IMB and PMB - IMB more associated with polyps)
2) Subfertility - submucosal fibroids prevent implantation
3) Lower abdominal pain - if degeneration occurring
4) Mass/pressure symptoms
- Urinary symptoms due to pressure on bladder
- Hydronephrosis if compressing ureters
- Constipation if pressure on bowel
- Lower limb oedema if pressure on veins
5) Bloating
How may a uterine fibroid affect a pregnancy?
Red degeneration
- Sudden onset pain and localised tenderness
- Mild pyrexia + mildly high WCC
- Often resolves spontaneously
Abnormal lie and obstruction if cervical
Can cause difficulty in CS
What investigations are done for fibroids?
- Bimanual pelvic examination (hard, irregular uterine mass) may be sufficient
- TV USS - size and location
- Saline infusion US better than TVUS and hysteroscopy in detecting submucous fibroids
- MRI needed if US unable to differentiate between ovarian mass + benign fibroid
- Hysteroscopy with biopsy if doubt over diagnosis
- FBC for anaemia
What management option is appropriate for a woman with fibroids who is asymptomatic?
Conservative management
Fibroids tend to shrink post-menopause due to falling oestrogen levels
Can monitor growth with examination or TVUS
What management option is appropriate for a woman with fibroids <3cm that do not distort the uterine cavity and does not want to conceive?
Medical management
First line = Mirena coil
Alternatives are POP or depot to reduce excessive bleeding
GnRH analogues - shrink fibroids and cause amenorrhoea (limited to 6 months treatment due to SE of oestrogen deficiency and fibroids tend to regrow when treatment ceased)
Ulipristal acetate - selective progesterone receptor modulator (SPRM) with predominantly inhibitory action. Inhibits cell proliferation and induces apoptosis
Mifepristone - progesterone receptor inhibitor which reduces bleeding but as it results in exposure of the endometrium to unopposed oestrogen, it can cause endometrial hyperplasia
What are some ddx for fibroids
Endometrial polyps - menorrhagia
Endometriosis - menorrhagia + constipation but no palpable mass
Chronic PID
Tuba-Ovarian abscess
Uterine sarcoma (very rarely fibroids can progress)
Ovarian tumour
Pregnancy
What is an endometrial polyp?
Who are they more common in?
What is the treatment?
= Adenoma
These are focal overgrowth of endometrium and are malignant in <1%
More common in women >40yr but can occur at any age
Treatment is usually resection during hysteroscopy and sent to histology
How common are ovarian cysts and why do they commonly arise?
= Benign ovarian tumour
Extremely common
Occur in 30% females with regular menses (eg luteal cysts as incidental findings on pelvic scans)
and 50% females with irregular menses
List the three main groups of ovarian cysts and their relative %
1) Functional = 24%
2) Benign = 70%
3) Malignant = 6%
What makes up 60% of all benign ovarian tumours?
Benign epithelial neoplastic cysts
What are the two types of benign ovarian cysts?
Serous cystadenoma
Mucinous cystadenoma
Serous cystadenoma:
- How do they appear?
- Most common in which age group?
- What % bilateral?
- What % malignant?
Serous cystadenoma
- Develop papillary growths that can be so prolific the cyst appears solid
- Most common in 40-50yr
- 30% bilateral
- 30% malignant
What should be the management of a pre-menopausal woman who is having periods with a cyst <10cm?
Not concerning or a cause for referral unless there are other suspicious features or she is symptomatic (eg pain)
Observe for 4-6 weeks
Rescan at 6wks when she is at a different point in her cycle
If it disappears/shrinks, continue with expectant management
What are some symptoms of ovarian cysts?
Asymptomatic unless complications occur so are usually an incidental finding
Chronic pain:
- Dull ache in lower abdo/low back pain
- Dyspareunia = endometrioma
- Cyclical pain = endometrioma
Pressure on other organs = urinary frequency, change in bowel habit
Irregular vaginal bleeding
Abdominal distention if > 14cm
Torsion, infarction or haemorrhage:
- Severe pain
- Torsion may be intermittent, presenting with intermittent episodes of severe pain
Rupture = peritonitis and shock
Which type of cyst is most prone to rupture?
Most common in endometrioma or dermoid cyst
What investigations are done for ovarian cysts?
Pregnancy test to rule out ectopic
Determine risk of malignancy index (RMI) for suspected ovarian cancer with following investigations:
1) USS Pelvis
2) CA125
- In premenopausal women with cyst > 5cm AND persisting for >6 weeks
- In postmenopausal women if cyst > 5cm OR persisting for >6 weeks
All premenopausal women with complex ovarian cysts should have CA125, aFP, bhCG performed and booked for elective cystectomy
How is the RMI calculated for ovarian masses?
RMI = U x M x CA125
U = US score, 1 point for each: multilocular cyst, mets, solid areas, ascites, bilateral lesions
(U=0 for 0, U=1 for US=1, U3 for US=2-5)
M = pre-menopause (1) or post-menopausal (3)
CA125 = serum CA125 level
RMI >200 should have CT abdo and pelvis and referred to secondary care
What is the management of ovarian cysts presenting acutely?
Most cysts presenting acutely are managed with analgesia as most will resolve spontaneously
However, if the woman presents with an acute abdomen or in shock due to ovarian torsion, rupture or haemorrhage of a cyst, urgent diagnostic laparoscopy or laparotomy may be required
(NB blood should be sent for biomarkers at this time as it will aid follow up)
What is the management of an ovarian cyst in postmenopausal women? (Low RMI, Moderate RMI, Severe RMI)
Low RMI (<25), simple, <5cm cyst and normal CA125 = follow up for 1yr with USS and CA125 every 4 months
Moderate RMI (25-250) = oophorectomy (usually bilateral recommended
Severe RMI (>250) = refer to cancer centre for full staging and laparotomy
In which population do ovarian cysts most commonly arise in?
Predominantly premenopausal women
Can occur perinatally
Uncommon in premenarchal and postmenopausal women
What can result in elevated CA125 levels?
Primarily a marker for epithelial ovarian carcinoma (only raised in 50% of early-stage disease)
Also:
- Diverticulitis
- Endometriosis
- Liver cirrhosis
- Uterine fibroids
- Menstruation
- Pregnancy
- Benign ovarian neoplasms
What is the management of simple ovarian cysts 50-70mm?
Yearly USS follow-up and those with larger simple cysts considered for further imaging (MRI) / surgical intervention
When may a cyst be considered not to be physiological?
Those that persist and increase in size
However, even in postmenopausal woman, persistent, unchanged, <10cm with normal CA125, likelihood of invasive cancer is low enough that observation is sufficient
What type of surgery is appropriate for ovarian cyst management?
Cystectomy preferred over oophorectomy in children and younger women to preserve fertility
Lapaoscopic usually preferred over open
How is ovarian torsion managed?
Laparoscopy with uncoiling of affected ovary and possibly oophoropexy
Salpingo-oophorectomy indicated if severe vascular compromise, peritonitis or tissue necrosis
Intervention within 6hrs means tissue will remain viable
If there is a positive PT in a patient with ? ectopic, what is the next line investigation?
Transvaginal ultrasound scan
If the uterus is empty on TVUS but the PT is positive, what are the three main differentials?
1) Very early pregnancy
2) Complete miscarriage
3) Ectopic pregnancy
What is looked for on a TVUS of ? ectopic pregnancy?
Location of pregnancy
Presence of foetal heartbeat - indication for surgical management
Presence of adnexal mass (doughnut shaped mass if the foetal pole is not distinguishable)
Presence of free peritoneal fluid
Thickened endometrium
What levels need to be monitored in an ectopic pregnancy and why?
serum beta-hCG levels
In ectopic they rise slowly or plateau (in normal pregnancy they rise rapidly and in miscarriage they fall rapidly)
The levels indicate which management option is appropriate
What is the gold-standard diagnostic investigation for ectopic pregnancy?
Laparoscopy
What presentation would make you suspect choriocarcinoma?
Continued vaginal bleeding after the end of pregnancy
Where do choriocarcinomas characteristically metastasise to?
Lungs
Are the symptoms more severe in complete or partial moles and why?
Less severe in partial because beta-hCG levels are lower than in complete moles
After beta-hCG level measurement, what further investigations are required for molar pregnancies and what would they show?
Transvaginal USS:
• Complete mole
- Snowstorm appearance of mixed echogenicity - hydropic villi and intrauterine haemorrhage
- No amniotic fluid
-Theca lutein cysts - functional ovarian cyst that originates from excessive amount of b-hCG; multiple; bilateral
• Partial mole
- Foetal parts may be visualised but show signs of structural abnormalities or growth restriction
- Increased placental thickness
Since TVUS is unreliable in the first trimester, histological examination is required for definitive diagnosis (this may require uterine evacuation)
What is the most common indication for hysterectomy?
Uterine fibroids
What are the different types of degeneration of fibroids?
Red degeneration - pregnancy
Hyaline/cystic degeneration - if fibroid outgrows its blood supply leading to central necrosis
Calcification - usually in post-menopausal women
What is leiomyosarcamata and when should it be suspected?
Malignant proliferation of fibroids
Suspect when a fibroid is rapidly growing in a post-menopausal woman
What would you suspect if a woman with fibroids presented with acute pain?
Pedunculated fibroids that had become torted
What are the most appropriate management options for symptomatic fibroids in women who want to conceive?
Transcervical resection of fibroid (TCRF) – hysteroscopy + resection with diathermy for submucosal
- Tiny risk of perforation
- Often use GnRH 6-8 weeks prior to reduce bulk of fibroid + endometrium
Myomectomy – for submucosal fibroids up to 4cm
- Preserves fertility (but there is risk of adhesions which reduce fertility)
- Prescribe GnRH agonists whilst waiting for surgery
- Complications - adhesions are the most common; bladder injury and uterine perforation are possible
What are the most appropriate management options for symptomatic fibroids >4cm in diameter? Summarise the pros and cons of each
Uterine artery embolization (UAE) – decreases blood flow to fibroid
- Not appropriate for women wanting to conceive – better to do myomectomy
- Avoids general anaesthetic
- Can be extremely painful recovery process
- Can cause necrotic + infected uterus
Hysterectomy – if pressure symptoms
- Is the only cure
- Reserved for women who have no wish to preserve fertility/have completed their family
On examination of ovarian cysts, what would suggest it was a benign cyst?
Freely mobile mass
What is the primary risk factor for ovarian torsion?
Ovarian enlargement (e.g. due to cysts, tumours, pregnancy, ovarian stimulation)
What often causes an ovarian cyst to rupture?
Physical activity
What are fibromas associated with?
Meig’s syndrome
- Pleural effusion
- Right sided ovarian fibroma
- Ascites
What are the different types of functional ovarian cysts and what do they arise from?
Follicular cyst - most common ovarian mass in young women; develops when a follicle does not rupture and release the egg but continues to grow
Corpus luteum cyst - enlargement and buildup of fluid in the corpus luteum after failed regression following the release of an egg
Theca lutein cysts - multiple cysts that develop bilaterally; arise from overstimulation of theca interna cells of follicles due to excess beta-hCG (so associated with GTD and multiple pregnancies)
What is a dermoid cyst and what does it arise from?
A dermoid cyst is a teratoma
They arise from primitive germ cells
What is a complex cyst? What can it indicate?
Multi-loculated (i.e. they are septated) or contain solid mass or blood flow within it
High suspicion of ovarian malignancy and should be treated as malignant until proven otherwise
