Gynae Flashcards
Define robotic assisted laparoscopy
Defined as the use of a fixed or mobile automatically controlled, multipurpose manipulator in >3 axes, to assist surgical procedures
The patient and surgeon may be separated during the procedure by a master-slave telerobotic system, which allows the surgeon to perform the operation in a remote location
RANZCOG position on robotic assisted laparoscopy
Current place for benign gynae procedures is yet to be established. Evidence that it takes as long or longer to perform with significantly more cost.
Gynaecologists should not perform RALS until they have reached the equivalent RANZCOG level skill level in conventional laparoscopy and can provide evidence of the on-site or off-site robotic surgery training necessary to complete the relevant procedure
Rate of complications at gynae laparoscopy
3-8/1000
50% of injuries at gynae laparoscopy occur at time of entry
Tests for correct Veress entry
Saline test - Withdraw to see if any fluid, pus, blood, faeces are aspirated, Instill saline to ensure no blockage, Withdraw syringe and watch if saline flows easily
Initial insufflation pressure should be relatively low (<5-8mmHg) and gas should be flowing freely - Highest sensitivity and specificity for correct placement
If incorrect placement after 3 attempts with veress, consider
Assistance from senior colleague
Alternate site for placement
Alternate entry
Cease the procedure completely
Informed consent for gynae exams and procedures
Adequate explanation Interpreter offered if required Patient has change to ask questions Support person Can decline exam Verbal consent obtained
Privacy for gynae exams and procedures
Privacy for derobing
Suitable cover for exam, e.g. gown
Always wear gloves
Don’t allow pt to remain undressed for any longer than is needed
Cease exam if consent uncertain or withdrawn
If no support person, professional suitably qualified and of acceptable gender to the patient could take on that role
If concern about patients understanding or level of consent, delay exam until f/u
Presence of an observer for gynae exams and procedures
Term observer being used instead of chaperone. Observe the consult or part of it on the doctor’s behalf.
Verbal consent for observer should be obtained from the patient and documented.
Observer must be suitably qualified, of a gender approved by the patient, respect the privacy and dignity of the patient,
When there is not agreement on the presence of a third person
Patient has the right to decline a third person being present. A doctor may decline to examine a patient on their own.
Doctor or patient may withdraw from consult until mutually acceptable third person available, or patient may be referred to another doctor
Nurses health study findings related to oophorectomy at hysterectomy
Median f/u 24y
Bilateral oophorectomy at time of hysterectomy for benign disease a/w:
- Decreased risk of breast and ovarian cancer
- Increased risk of all-cause mortality, and fatal and non-fatal CHD
At no age was oophorectomy a/w increased survival
Oophorectomy not associated with decreased survival in women >55y at the time of hysterectomy + oophorectomy
Potential risks of oophorectomy at time of hysterectomy for benign disease
Increased: mortality due to coronary heart disease, morbidity and mortality due to osteoporosis related fracture, risk of cognitive dysfunction, incl dementia, depressive and anxiety symptoms
In premenopausal women: more severe and prolonged vasomotor symptoms than those seen following natural menopause, reduction in libido and sexual dysfunction
Removal of tubes at hysterectomy?
- Growing evidence that high-grade serous tumours of ovary and peritoneal surface epithelium may originate in the fallopian tubes
- Removal does not appear to increase surgical complications or impact ovarian function
- No population based data to quantify the risk-benefit profile
Incidence of leiomyosarcoma
0.02-0.3% depending on study population
Risk factors for leiomyosarcoma
Age (mean age of diagnosis: 60) Menopausal status African American ethnic background Current or prior tamoxifen exposure Hx of pelvic irradiation Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome Survivors of childhood retinoblastoma
Clinical features suggestive of leiomyosarcoma
Rapidly expanding mass
PMB or variants of AUB (if premenopausal)
Ascites
Lymphadenopathy
Evidence of secondary spread
May be an elevation in LDH related to increased cell turnover
Imaging features suggestive of leiomyosarcoma
Large size or large interval growth Tissue signal heterogeneity Central necrosis Ill-defined margins Ascites Metastases
Define morcellation
Defined as the division of a large specimen into smaller fragments to permit removal from the peritoneal cavity
Types of mocellation
Manual - use a scalpel
- Bivalving, coring
Electromechanically - devices designed for this purpose
- Advanced surgical technique
- Use of devices restricted to practitioners at AGES-RANZCOG level 5 and above
Risks of morcellation
Patient injury - tissue or vessels may be inadvertently injured
Dissemination - fragments of tissue may disseminate throughout the peritoneal cavity. Especially with electromechanical morcellators as create a larger volume of small fragments
Pathology - the size of fragments and loss of anatomical relationships may complicate the diagnosis by the pathologist
Precautions when using a morcellator
- No suspicion of malignancy on preoperative or intraoperative assessment
- Maintain the tip of the instrument in view at all times
- Maintain control of the specimen at all times
- Feed the specimen into the morcellator in a controlled manner
- Minimise spillage of specimen fragments wherever possible
- Post-morcellation retrieval of all macroscopic fragments
To minimise risk of dissemination with morcellation
- Case selection
- Pre-op assessment, specifically to assess the risk of malignancy
- Consent should involve mechanism of tissue extraction
- Intra-op assessment - if suspicious pathology, adapt plan
UAE procedure
Involves the placement of an angiographic catheter into the uterine arteries via the common femoral artery, followed by injection of embolic particles until the flow becomes sluggish in both uterine arteries. Aims to reduce uterine blood flow at the arteriolar levels –> ischaemic injury to the fibroids –> necrosis and shrinkage.
Surrounding normal myometrium allowed to recover under supply of vaginal and ovarian collateral circulations
UAE - Absolute contraindications
Asymptomatic fibroids
Pregnancy
PID (recurrent or current)
Suspected or known uterine malignancy
UAE - relative contraindications
Desire to conceive - High quality data lacking
Postmenopausal status
Fibroid location - Submucosal or subserosal with narrow stalk - sterile peritonitis or intrauterine infection.
Number / size of fibroids
UAE outcomes
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
UAE - risks
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%)
Cochrane 2014 - UAE vs. surgery (myomectomy, hysterectomy) for symptomatic fibroids
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
EMMY trial
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
Concerning outcomes of UAE that could affect reproductive potential
- 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
Fertility rates after UAE
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
Pregnancy outcomes with UAE
No difference in PTB, IUGR, malpresentation
Significantly higher rates of CS, PPH and miscarriage
RANZCOG recommendation re. UAE in those wishing future fertility
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
Effect of fibroids on fertility
poorly understood and most appropriate management remains controversial
Fibroid position appears key
Imaging to assess fibroid position in infertility
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
Impact of subserosal fibroids on fertility
do not appear to have a significant effect on fertility outcome
Impact of intramural fibroids on fertility
may be associated with reduced fertility and increased miscarriage rate
- There is insufficient evidence to determine whether myomectomy for IM fibroids improves fertility outcomes
Impact of submucosal fibroids on fertility
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
Indications for myomectomy in infertile women
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
Medical management of fibroids and infertility
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
PCOS prevalence in Australia
6-7% of the population
Conservative estimate - recent data suggests higher, particularly in Aboriginal population
Rates of IGT and T2DM with PCOS
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
Screening for impaired glucose tolerance in women with PCOS
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
Screening cardiovascular risk in PCOS
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
Metabolic syndrome
- Elevated BP >130/85
- Increased waist circumference >88cm
- Elevated fasting blood glucose levels
- Reduced high density lipoprotein cholesterol levels
- Elevated triglyceride levels
OSA and PCOS
Independent risk factor for CVD
More common in PCOS - remains significant even when controlling for BMI
Screen for symptoms - snoring, daytime fatigue / somnolence
Endometrial protection in PCOS
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
Lifestyle management in PCOS
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
Insulin sensitising agents in PCOS
Routine use not recommended.
Role with increased glucose tolerance or T2DM has been diagnosed.
Bariatric surgery and PCOS
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
Ovulation induction and PCOS
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
Consent for those with intellectual disability - minor, reversible procedures
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.
Consent for those with intellectual disability - Procedures that are intended or are reasonably likely to render a patient permanently infertile, or involve a TOP
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
RANZCOG abortion recommendations
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
Staff involvement in TOP
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
Considerations for late abortion
> 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
General requirements prior to TOP
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
Gestation threshold for OP MTOP and outcomes
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
RANZCOG med recommendations for STOP <9/40
Mifepristone 200mg, then misoprostol 800mcg (buccally) within 48h
Summary of Australian NCSP
5 yearly HPV screening, with reflex liquid-based cytology
25-74y
Self-testing possibly with practitioner facilitation
NCSP registry established in 2017
Benefits of new Australian NCSP
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)
Oncogenic HPV types implicated in cancers of:
Cervix Vulva Anus Penis Some head and neck cancers
Main HPV types accounting for cervical cancer
Types 16 and 18 account for ~70% of cervical cancers
Main HPV types accounting for genital warts
Non-oncogenic types 6 and 11
Description of HPV vaccine - gardasil 9
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
Outcomes from HPV vaccination
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%
Safety data for HPV vaccination
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
HPV vaccination schedule in NZ
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
Incidence of GTD
1:200-1000 pregnancies
Incidence of GTD after a live birth
1 / 50,000
Incidence of GTD higher in..
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)
Definition of gestational trophoblastic neoplasia
Used to described GTD requiring chemotherapy or excisional treatment because of persistence of HCG or presence of metastases
GTN follows…
- Hydatidiform mole (60%)
- Previous miscarriage / abortion (30%)
- Normal pregnancy or ectopic (10%)
What is a hydatidiform mole?
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
Partial mole
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
Complete mole
Diploid
Derived from paternal duplication (46XX, 75%) or dispermic fertilisation of an ‘empty’ ovum (lacking maternal genes) (46xx or 46XY, 25%)
GTD.
Persistence or change into malignant disease requiring chemotherapy occurs in….
0.5-4% of partial moles
15-20% of complete moles
Gestational choriocarcinoma commonly occurs after
Most commonly follows a complete molar pregnancy (25-50%)
Within 12 months of a non-molar abortion (25%)
After a term pregnancy (25-50%)
Symptoms of choriocarcinoma
PVB
Pelvic mass
Symptoms from distant metastases (liver, lung, brain)
Diagnosis considerations for choriocarcinoma
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)
Presentation of placenta site trophoblastic tumour
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
Treatment of placenta site trophoblastic tumour
Treatment is usually hysterectomy
Tumour is relatively chemoresistant
Aetiology of epithelioid trophoblast tumour
Distinctive but rare form of GTN
Disease of intermediate trophoblast cells
Presentation of epitheliod trophoblast tumour
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
Treatment of epithelioid trophoblast tumour
Primary treatment: hysterectomy
Tumours are resistant to chemotherapy
High mitotic index, atypia and vascular invasion confer a poorer prognosis
Vaginal GTN
Vaginal GTN most commonly located in the fornices or suburethrally
Highly vascular and bleed heavily
Avoid biopsy
Second evacuation for GTD and persistently elevated HCG
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
Chance of recurrent GTD
1 in 70 chance of conceiving further molar pregnancy
Serum half life of hCG
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)
Phantom HCG?
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
Hysterectomy for GTD
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
Mode of action of tamoxifen
Selective estrogen receptor modulator (SERM)
- Anti-oestrogen effects in the breast
- Oestrogenic effects in other tissues including blood (VTE risk), bone and endometrium
Indications for tamoxifen
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
Gynae effects of tamoxifen
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
Endometrial effects of tamoxifen
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
Endometrial screening in women on tamoxifen
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)
LNG-IUS use in women on tamoxifen
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
Tamoxifen and pregnancy
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
What is vaginal rejuvenation?
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
FDA reported serious adverse events of vaginal rejuventation procedures
- Vaginal pain
- Burning
- Dyspareunia
- Chronic pain
- Lack adequate supporting efficacy data
RANZCOG (2019 statement) re vaginal rejuventation?
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
