gynae Flashcards
Ectopic pregnancy
Developing blastocyst implants anywhere besides endometrial lining of uterine cavity
Where are most ectopics found
Tubal 93% (70% ampullary)
Risk factors for ectopic pregancy
Patient factor:
infertility
>40years
Lifestyle factors:
sexual promisquity
Past/ current smoker
Gynae/ obs Previous tubal surgery (assisted reproductive techniques) confirmed genital tract infection previous miscarriage previous ectopic previous induced abortion sterilization tubal pathology (esp chlamydia) (PID) Diethylstilbestrol exposure Previous myomectomy
What are protective factors of ectopic
All contraceptives
Pathology of ectopic pregancy
invasion of the small blood vessels leading to extraluminal bleeding and haematoma
irregular dilatation of the fallopian tube
Triad of symptoms in ectopic pregnancy
Amenorrhoea
Vaginal bleeding
Abdominal Pain
The pain may be localized or diffuse. There may be a transient relief of pain following tubal rupture when stretching of the serosa ceases. (patient may feel dizzy)
Investigations in ectopic pregnancy
- Ultrasound, to check if intrauterine.
(Sign of intrauterine pregnancy is gestational sac
surrounded by double echogenic ring)
-empty uterus + complex cystic mass and free fluid in
pouch of douglas = highly suggestive of ectopic.- May see adnexal mass
At what B HCG level should one visualise an intrauterine pregnancy via transvag scan
> = 1500
and at a crown rump length of >7mm one should see the heart
Unruptured ectopic management -expectant
When no evidence of rupture in a U/S confirmed ectopic
B -hcg level < 1000IU/ L & declining within 48 hours
stable/ asymptomatic (no blood in pelvis)
Patients followed up twice weekly, until level is 50% of initial value, then weekly till level undetectable.
Unruptured ectopic- medical management
Methotrexate (first line) 1mg/Kg IM Indications -no evidence of rupture - hemodynamically stable -B-HCG < 3000 IU - No fetal cardiac activity on U/S (<4cm) - Normal FBC U&E *repeat dose if levels don´t fall adequately
Unruputured ectopic- surgical management
Only if medical Rx won´t work B HCG >3000 fetal cardiac activity adnexal mass >4cm *usually laparoscopy...consider salpingostomy/salpingectomy if there is contralateral tubal disease with a strong desire for future fertility.
Risk factors for ruptured ectopic
B HCG >10 000IU
Never used contraceptives +
Hx of tubal damage, infertility and induction of ovulation
How is a ruptured ectopic diagnosed
Clinical diagnosis
* no need for b hcg to diagnose…
Obviously needs a positive pregnancy test though
How do we predict volume of blood loss in a ruptured ectopic
The shock index:
( heart rate/ systolic blood pressure)
but.. knowing signs of hypovelemia is probably more practical (according to Dr Trip)
How do we define massive haemorrahage in a patient with a ruptured ectopic
acute loss of >25% of total volume
Stop bleeding, and rescus
- Rx will usually include laparotomy (salpingectomy)
Management of Massive bleeding (eg ruptured ectopic )
- Preliminary diagnosis of massive bleeding
- Obtain a quick hx, assess vitals (quick quick)
- Amenorrhoea
- Abdominal pain
- Bleeding per vagina
- Nausea and vomiting
- Dizziness and fainting
- No contraception - Initial intervention
-Call for help
- secure airway, give Oxygen (mask)
-Large bore (16G) x 2
-Draw blood for complete blood count, clotting profile
-crossmatch 4 units of packet red cells
-pregnancy test
-Infuse 2 litres of crystalloid rapidly, followed by basal
infusion of 200ml/hr - Second assessment
-Examinet pt
-reassess diagnosis
-repeat vitals, monitor urine output, o2 SATS
- prepare pt for theatre - Treatment goals:
-Hb 7-10
-Platelets >100 000
-INR <1.5- Avoid hypothermia, hypocalcemia, metabolic
alkalosis and hyperkalemia.
-MAP 70-80mmHg
-Urine output of >30ml/hr
- Avoid hypothermia, hypocalcemia, metabolic
Diagnosis of advanced abdominal pregnancy
Abdominal pain, tenderness
N/V
Vaginal bleeding
Examination:
- abnormal lie
- easily palpable fetus
- abnormally senstive abdomen
- displaced cervix/ barely enlarged uterus
Diagnosis on ultrasound
Causes of abnormal uterine bleeding
PALM COEIN
- Polyps
- Adenomyosis
- Leiomyomata
- Malignancy and hyperplasia
- Coagulopathy
- Ovulatory dysfuntion
- Endometrial
- Iatrogenic
- Not yet classified
What is dysfunctional uterine bleeding?
Abnormal uterine bleeding without any organic pathology.
diagnosis by exclusion
either Ovulatory or Anovulatory
Ovulatory Dyfunctional uterine bleeding:
pathophysiology and presentation
Occurs due to local factors originating in the endometrium.
-Poor formation or function of corpus luteum
-Irregular shedding of the endometrium (due to
persistence of the corpus luteum)
Anovulatory dysfunctional uterine bleeding
Abnormality of hypothalamic- pituitary-ovarian axis.
Path: bleeding comes from an endometrium that has not been preceded by ovulation. therefore luteal secretory changes will be absent.
-Excessive oestrogen stimulation of endomentrium.
(due to graafian follicle which didn´t rupture, leading to
excessive rise in oestrogen levels. endometrium
becomes hyperplastic. Eventually oestrogen levels
fluctuate and when below critical level endometrium is
shed…heavy bleeding.
-Inadequate stimulation of endometrium
Circulating oestrogen levels are low. when oestrogen
falls below critical level, bleeding occurs. (irregular
acyclical)
History in abnormal uterine bleeding
How long is the cycle? length duration amount clots symptoms of ovulation (slight cramping or pain, breast tenderness, bloating, light spotting)
Changes in menstruation ? Medical hx and non-gynae medication Sexual hx and contraceptive use Past gynae hx, pap smears and surgeries, and medications Familial bleeding tendencies
What to look for on examination in abnormal uterine bleeding
General: shock, anemia, purpura and petechiae
stigmata of endo disease (goitre, obesity,
striae).
Pelvic exam: local lesions, feel adnexa.
exclude rectal & urethral bleeding.
Examine breasts
Special investigations in abnormal uterine bleeding
- preganancy test
- Hb (FBC, platelets, coagulation studies, crossmatch)
- Pap smear
- U/s: look @ endometrial thickness (trans vag & abdo)
- Hysteroscopy: direct visualisation & biopsy
Management of abnormal uterine bleeding
Acute…stabalise, physical exam to establish cause
HORMONAL THERAPY
- Oral progestogen (converts to secretory endo), give
for 7-10 days. Bleeding occurs once drug withdrawn.
Then give ovulatory agent, or progesterone agent/
contraceptive pill.
- High dose oestrogen followed by oral progestogen:
only if bleeding is due to atrophic endometrium.
- Combination oral contraceptive pill
NON-HORMONAL: antifibrinolytic therapy (tranexamic acid- Cyclokapron)
SURGICAL Rx: D & C
Definitive management of abnormal uterine bleeding
Expectant (esp teenagers)
MEDICAL Mx
-Antifibrinolytic drugs
-NSAIDS (reduce prostaglandin synthesis.
Prostaglandin causes vasodilation)
-COCP
-Progestogens, for pt´s where oestrogen is
contraidicated and in anovulatory DUB
-Danazol
-GnRh analogues (inhibit FSH)
SURGICAL
-Hysterectomy and endometrial ablation.
side effects of transexamic acid/ cyclokapron
N/ V dizziness tinnitis rashes abdo cramps
Thrombosis (always check pt´s risk factors for thrombosis)
Amenorrhoea
Primary: Pt reached 16 & never menstruated
Secondary: Cessation of menstrual bleeding for at least 3 months.
Menorrhagia
excessive bleeding
Polymenorrhagia:
occurs over <21 days
more frequent bleeds, shortened cycle length
Oligomenorrhagia:
scanty menstruation/ long cycles over 35 days. associated with anovulation.
Menorrhagia
> 80ml/ cycle. Increased cycle duration
cycle regular
(66% have Fe def anemia )
Metrorrhagia: irregular bleeding at any time between menstrual periods…
What is pelvic inflammatory disease:
Acute infection of the upper genital tract structures involving any/‘ all of uterus, tubes and ovaries.
Neighboring organs may also be affected. (endometritis, salpingitis, oophoritis, peritonitis, tubo-ovarian abscess)
Usually sexually transmitted
Risk factors for pelvic inflammatory disease.
Early sexual debut <25years Previous PID Multiple partners, or new partner, symptomatic partner Other STD´s Sex during menses Bacterial vaginosis
What is bacterial vaginosis:
Polymicrobial condition where normal lactobacilli are replaced by aerobic/ anaerobic bacilli. Presents with discharge.
Causative agent often gardnerella vaginalis.
Protective factors in PID
Barrier contraception
Oral contraception
Tubal ligation
Pregnancy
What is the normal dominant bacteria in the female genital tract
hydrogen peroxide producing lactobacillus acidophilus
Causitive agents in PID
chlamydia and gonorrhoea. Gardnerella vaginalis
Secondary invaders: anaerobes or gram negatives
- Streptococci
- e.Coli
- h.Influenza
- pseudomonas
- Klebsiella
Pathology: Mild PID
tubes swollen, tubes freely mobile
Tubal ostea patent
sticky seropurulent exudate us present at fimbrial end
Pathology of Moderately severe PID
Fibrin deposits cover serosal surfaces of the tubes
Tubes not mobile, may adhere to overies, broad ligament and bowel
Pathology of sever PID
Pelvic peritoneum involved Tubal ostea sealed Pelvic anatomy distorted Abscess...rupture...peritonitis Hydrosalpinx (when pus of an abscess replaced by serous fluid, walls of tube become thin and flattened, tube filled with clearwatery fluid)
Diagnosis of PID
Lower abdo pain (worse during coitus)
Cervical excitation tenderness
Abnormal uterine bleeding (30%)
Discharge
Normal signs of infection:
hypotension
dehydration/ pyrexia
tachypnoae/ tachycardia
How do patients with an aerobic infection (PID) present
usually older patients, presents with repetitive episodes of infection,
Pyrexia and demonstrable palpable adnexal mass
