Gynae Flashcards

Question

UAE outcomes

Answer 1

Reduced pressure / bulk-related symptoms in ~60% Reduced AUB (heavy) in 7-90% Reduced pain in ~80% The 2 largest RCTs (REST, EMMY) revealed reintervention rates of 28.4-35% at 5-10y compared to 2-10.7% for surgical groups

Answer 2

Risk of minor complication 30-45% Risk of major complications - 5% Procedural: Groin haematoma, Arterial thrombosis, Pseudo-aneurysm Early: 'Embolisation syndrome' (pain, nausea, malaise, fever), Vaginal discharge, pelvic infection (incl pyomyoma), expulsion of necrotic submucosal fibroid Late: Ovarian insufficiency, Failure of response, re-intervention, VTE (0.286%)

Answer 3

``` Increased: - Minor complications - Number of unplanned reviews and re-admissions after discharge - Surgical reintervention rate Decreased: - Length of hospitalisation - Procedure duration - Resumption of ADL ``` No significant difference in: Intra procedural complications, Short or long term major complications, Patient satisfaction at 2 and 5y, long-term ovarian failure rates

Answer 4

Dutch, randomised trial Hysterectomy rate in the UAE group - 35% by 10y. 5% performed immediately after failed bilateral UAE, Further 19% resorted to hysterectomy by the end of 2y due to inadequate response 65% of women avoided hysterectomy by undertaking UAE High rate of re-intervention may negate any initial cost-benefit provided by UAE

Answer 5

- Non-targeted embolisation --> ovarian embolisation and impaired ovarian reserve - Decrease in endometrial volume due to an inadequate blood supply - An otherwise healthy myometrium adversely affected by embolisation --> contraction disturbance and implantation failure

Answer 6

1 small RCT comparing UAE to myomectomy - Pregnancy rates were significantly higher, with lower miscarriage rates in myomectomy group - Obstetric and perinatal outcomes in ongoing pregnancies were similar between the groups 1 prospective cohort study - 'fertility-sparing' protocol with limited embolisation of both uterine arteries - Monthly fecundability was 0.1% - No control group with surgical treatment - Authors commented that UAE did not improve fertility potential and may have worsened it

Answer 7

No difference in PTB, IUGR, malpresentation | Significantly higher rates of CS, PPH and miscarriage

Answer 8

Due to the lack of good quality evidence, caution should be employed to avoid routine use of UAE in young patients with fibroid disease wishing to conceive

Answer 9

poorly understood and most appropriate management remains controversial Fibroid position appears key

Answer 10

Optimal imaging techniques: - MRI - Sonohysterography - Hysteroscopy - however may under-represent submucosal lesions because of raised intrauterine pressure HSG and TVS are insufficiently sensitive or specific

Answer 11

do not appear to have a significant effect on fertility outcome

Answer 12

may be associated with reduced fertility and increased miscarriage rate - There is insufficient evidence to determine whether myomectomy for IM fibroids improves fertility outcomes

Answer 13

associated with reduced fertility and an increased miscarriage rate - Hysteroscopic myomectomy is likely to improve fertility outcomes, but only poor quality studies therefore further research is required

Answer 14

Those undergoing ART who have demonstrated SM fibroid(s) Those with symptomatic fibroids (e.g. HMB, pressure symptoms) - trial evidence does not show clear fertility benefit, but presence of symptoms may justify the intervention Couples with multiple failed ART cycles and the female has IM fibroids

Answer 15

Medical management not recommended as delays efforts to conceive - Short term use of GnRH analogue can be useful for pre-op correction of anaemia or short-term reduction in fibroid volume

Answer 16

6-7% of the population | Conservative estimate - recent data suggests higher, particularly in Aboriginal population

Answer 17

Australian cohort with PCOS - Impaired glucose tolerance 15.6% - T2DM 4% Risk independent of, yet exacerbated by obesity. Lean women with PCOS has a 2-fold increase in incidence of T2DM compared to controls

Answer 18

2h OGTT for screen - Some authorities recommend screening all women diagnosed with PCOS - Others recommend if fasting BSL >5.6 mmol/l, BMI >30, strong FHx of GDM, lean women >40y - Consider repeat testing over time as increased incidence of T2DM over time and conversion of insulin resistance to T2DM

Answer 19

Screen by determination of BMI, fasting lipid and lipoprotein levels and metabolic syndrome risk factors Prospective studies have not yet identified an increase in cardiac events in women with PCOS Indirect evidence of increased cardiovascular risk

Answer 20

- Elevated BP >130/85 - Increased waist circumference >88cm - Elevated fasting blood glucose levels - Reduced high density lipoprotein cholesterol levels - Elevated triglyceride levels

Answer 21

Independent risk factor for CVD More common in PCOS - remains significant even when controlling for BMI Screen for symptoms - snoring, daytime fatigue / somnolence

Answer 22

if PCOS and oligo or amenorrhoea - Induction of regular withdrawal bleeds (at least every 3-4 months) is advised using cyclic progestagens for at least 12 days or the COCP - Mirena is an option

Answer 23

Achievable goals such as 5-10% weight loss in those with excess weight yields significant clinical improvements . Dietary advice should focus on total calorific intake, low glycaemic index diets are preferred. Aerobic exercise recommended - 30 mins / day decreases central obesity and increases insulin sensitivity

Answer 24

Routine use not recommended. | Role with increased glucose tolerance or T2DM has been diagnosed.

Answer 25

Should be considered where obesity is not controlled by lifestyle modifications Balance against risks of surgery - 0.1-1% mortality, risk of bowel obstruction, infection, oesophagitis, nutritional abnormalities Performed when standard weight loss regimes have failed in PCOS women with BMI >40, or >35 with high-risk obesity related condition

Answer 26

due to the increased risks of pregnancy in women with obesity, the use of ovarian stimulation for women with a BMI >35 is contraindicated. Metformin alone proves ineffective in large-scale RCT - Metformin associated with lower ovulation rate, lower live birth rate, and no reduction in miscarriage rate

Answer 27

If woman provides verbal consent, may obtain written legal consent from the person responsible, e.g. appointed medical agent under EPOA, patient's spouse or domestic partner, primary carer, or nearest adult relative.

Answer 28

Reversible methods should be considered in preference to irreversible surgical options Mandate an application to an independent statutory body such as a guardianship board or public advocate Check local regulations Consultation with others experienced in the care of young women with disabilities prior to considering irreversible approaches is strongly recommended

Answer 29

Access should be on the basis of health care need and should not be limited by age, SE disadvantage or geographic isolation - Non-availability of abortion services has been shown to increase maternal morbidity and mortality Women should have access to professional counselling Health practitioners should be aware of the legislation regarding abortion where they practice

Answer 30

No member of the team should be expected to perform abortion against their personal convictions, but all have a professional responsibility to inform patients where and how such services can be obtained and to be respectful of the woman's decision

Answer 31

>20 weeks Multiple pregnancy discordant for severe fetal abnormality Delay in diagnosis, or determining prognosis, in the setting of fetal abnormality Psychosocial circumstances Maternal medical conditions College supports the availability of legal abortion for those women facing circumstances where the decision regarding TOP is being considered at late gestational age either because of clinical necessity or because of delayed fetal diagnosis or presentation

Answer 32

All women should be given accurate info and counselling should be available Clinical assessment including medical Hx and exam Exclude contraindications USS to confirm gestation and exclude ectopic Consider screening for STI and/or antibiotic prophylaxis Blood group and Rh(d) status +/- anti-D POC treated in accordance with local and legislative protocols Plan for future contraception Written consent should be obtained prior to the commencement

Answer 33

Gestation <9+0/40 (63 days) Abundant evidence to support option of misoprostol being self-administered at home if <9/40 95% will have complete expulsion of POC within a few hours of miso with mife + miso regime 5% will need ERPOC for heavy or prolonged bleeding, or for continuing pregnancy

Answer 34

Mifepristone 200mg, then misoprostol 800mcg (buccally) within 48h

Answer 35

5 yearly HPV screening, with reflex liquid-based cytology 25-74y Self-testing possibly with practitioner facilitation NCSP registry established in 2017

Answer 36

More effective than old regime, just as safe, and is effected to result in a significant reduction (24-36%) in incidence and mortality from cervical cancer in Australian women compared to program it replaces (2 yearly cervical cytology)

Answer 37

``` Cervix Vulva Anus Penis Some head and neck cancers ```

Answer 38

Types 16 and 18 account for ~70% of cervical cancers

Answer 39

Non-oncogenic types 6 and 11

Answer 40

Made from Virus Like Proteins - Does not contain live, attenuated or killed viruses IM infection Induces antibody response Does not treat existing lesions Gardasil 9 - contains HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58 - potentially prevents 90% of cervical cancers - Trials demonstrated 95-100% efficacy against HPV types in the vaccine

Answer 41

In countries with high HPV vaccine coverage, there has been a profound reduction in the number of genital wart cases Data suggests elimination may be possible In young women, there has been a decline in incidence of histologically confirmed HG abnormalities of almost 75%

Answer 42

OK when breastfeeding Not recommended during pregnancy (note no adverse effects reported) Anaphylaxis rate: 1-3 in every million doses No other serious responses have been identified Minor adverse reactions - injection site reactions, fever, headaches, dizziness, muscle pain Immune response may be smaller in the immunocompromised patient

Answer 43

Registered for use in females 9-45y and males 9-26y Offered to children aged 11-12y Funded for males and females 9-26y (inclusive) - 9-14 get 2 dose schedule (0 and 5-13 months) - 15-26y get 3 dose schedule (0, 2, and 6 months) Effectiveness is optimal when given <15y and prior to onset of sex

Answer 44

1:200-1000 pregnancies

Answer 45

1 / 50,000

Answer 46

Incidence higher at both ends of the reproductive spectrum (I.e. <15y and >45y) Evidence of ethnic variation (higher in Asian populations 1/390 vs 1/750)

Answer 47

Used to described GTD requiring chemotherapy or excisional treatment because of persistence of HCG or presence of metastases

Answer 48

- Hydatidiform mole (60%) - Previous miscarriage / abortion (30%) - Normal pregnancy or ectopic (10%)

Answer 49

Separated into complete and partial moles based on genetic and histopathological features In early pregnancy (<8-12/40) can be difficult to separate the two on H&E microscopy - other tests (e.g. ploidy, p57) will often be required

Answer 50

Triploid - 2 sets of paternal and 1 maternal haploid set May also be tetraploid or mosaic Embryo usually present, that dies by week 8-9 Most often occur following dispermic fertilisation Contain embryonic or fetal material such a fetal red blood cells

Answer 51

Diploid Derived from paternal duplication (46XX, 75%) or dispermic fertilisation of an 'empty' ovum (lacking maternal genes) (46xx or 46XY, 25%)

Answer 52

0.5-4% of partial moles | 15-20% of complete moles

Answer 53

Most commonly follows a complete molar pregnancy (25-50%) Within 12 months of a non-molar abortion (25%) After a term pregnancy (25-50%)

Answer 54

PVB Pelvic mass Symptoms from distant metastases (liver, lung, brain)

Answer 55

Difficult pathological Dx as frequent haemorrhage and necrosis This is a tumour that crosses the placenta, therefore newborn born to a mother newly diagnosed with choriocarcinoma needs to be investigated to exclude disease (urinary HCG)

Answer 56

Very rare Frequently presents as slow growing tumour a number of years after a molar pregnancy, non-molar abortion or term pregnancy ~1/3 present with metastases Some patients present with hyperprolactinaemia or nephrotic syndrome HCG levels relatively low or normal relative to the volume of disease Consider in cases of relapse

Answer 57

Treatment is usually hysterectomy | Tumour is relatively chemoresistant

Answer 58

Distinctive but rare form of GTN | Disease of intermediate trophoblast cells

Answer 59

Typically characterised by a long interval from the antecedent pregnancy, and more commonly followed a term pregnancy HCG levels usually much lower than with a molar pregnancy Less aggressive than choriocarcinoma Metastatic potential similar to PSTT

Answer 60

Primary treatment: hysterectomy Tumours are resistant to chemotherapy High mitotic index, atypia and vascular invasion confer a poorer prognosis

Answer 61

Vaginal GTN most commonly located in the fornices or suburethrally Highly vascular and bleed heavily Avoid biopsy

Answer 62

Still 70% change of requiring chemotherapy with second evacuation Also 8% risk of uterine perforation Consider hysteroscopy Not recommended if HCG >5000 or evidence of metastases

Answer 63

1 in 70 chance of conceiving further molar pregnancy

Answer 64

Serum half-life of hCG is 24-36 hours | Level is roughly linked to the number of tumour cells (5IU/l approx equates to 104-105 tumour cells)

Answer 65

False positive result for serum HCG Due to human heterophilic antibodies - antibodies that can bind to non-human immunoglobulins present in commercial HCG assays False positive serum HCG results can be excluded if urine HCG is negative or by serial dilution of the serum Heterophilic antibodies are not observed in the urine

Answer 66

Not recommended for treatment of molar pregnancy routinely Consider if persistent GTD to reduce the need for chemo 2 small American studies found the changes of needing chemotherapy after hysterectomy for molar pregnancy are 3-10%, i.e. halved but not eliminated Need for careful monitoring remains

Answer 67

Selective estrogen receptor modulator (SERM) - Anti-oestrogen effects in the breast - Oestrogenic effects in other tissues including blood (VTE risk), bone and endometrium

Answer 68

ER positive breast cancer - Reduces the risk of breast cancer recurrence, new breast cancers and mortality from breast cancer Risk reduction in pre-menopausal women with a high inherited risk of breast cancer - Effect on ovarian function unknown

Answer 69

Oestrogen-like changes in the vaginal epithelium of some patients Stimulation of endometriosis --> worsening Sx Stimulation of growth of benign fibroids Can induce ovulation May be teratogenic

Answer 70

Benign cystic hyperplasia - cystic dilated endometrial glands with condensed peri-glandular stroma and atrophic overlying epithelium --> USS appearance falsely suggestive of cystic endometrial hyperplasia Increased incidence of: - Benign endometrial polyps - Endometrial proliferation - Hyperplasia If endometrial pathology prior to starting tamoxifen, statistically significantly higher risk of developing lesions at 2y compared to patients without Increased risk of endometrial adenocarcinoma in post-menopausal women (RR = 4.01). Cumulative risk of endometrial cancer with Tamoxifen use: 1.6% at 5y, 3.1% at 5-14y Population based studies suggest a small increase in the risk of uterine sarcoma with tamoxifen

Answer 71

Routine screening not recommended Incidence is low - 2-3/1000 women per year If incidental finding of thickened endometrium on USS, management controversial - Consider other risk factors (obesity, HTN, FHx, duration of tamoxifen - particularly after 2y)

Answer 72

LNG-IUS should not be used to prevent endometrial cancer in women on tamoxifen - Cochrane - no clear evidence that LNG-IUS prevents endometrial cancer in with breast cancer on tamoxifen - No conclusive data on whether risk of breast cancer recurrence or breast-cancer related deaths increased with use of LNG-IUS

Answer 73

If oestrogen-sensitive breast cancer on tamoxifen, advise to use non-hormonal methods of contraception Tamoxifen use in pregnancy may increase risk of congenital abnormalities - Month wash out period recommended at cessation before attempting pregnancy

Answer 74

Refers to devices that deliver thermal energy to the vaginal mucosa Marketed for the treatment of vaginal menopausal symptoms, sexual dysfunction, urinary incontinence Devices include CO2 and Erbium lasers, and radiofrequency ablation Erbiu laser has approval from the Therapeutic Goods Administration (TGA, Au) for the treatment of vaginal atrophy

Answer 75

- Vaginal pain - Burning - Dyspareunia - Chronic pain - Lack adequate supporting efficacy data

Answer 76

strongly discourages the performance of any surgical or laser procedure that lacks current peer reviewed scientific evidence other than in the context of an appropriately constructed clinical trial At present, no evidence they are effective, enhance sexual function, or improve self-image