Gynae Cases Placement Flashcards
49 year old woman present Left iliac fossa pain for 1 month Menorrhagia Scans show left ovarian cyst increase in size by 5cm in 2 months and also shows a fibroid. Not menopausal
She is taking tranexamic acid prescribed by gp. Para 3.
How would you manage this?
Would be tempted for mirena coil for the HMB. And then measure Ca125 + laparoscopic drainage of the cyst due to growth rate
But;
She’s had her kids, just offer BSO, will solve issue of cyst pain. Will resolve fibroids as well due to less oestrogen.
Councilling
Ask her if that’s what she wants.
Double check she doesn’t want more kids.
Ask if she wants hrt after as she will go into menopause straight. But she is close to menopause anyways.
The surgery is a day case. It’s laparoscopic
She will need to self isolate for 3 days prior to it to prevent covid
A 24wk pregnant patient presents to triage with a rash around the left eye. On inspection it’s a vesicular rash. She came in last week started on oral abx, for incontinence as msu showed mixed bacterial growth.
What is the differential and how do we manage this?
Dfx: herpes. Patient mentions she has previously had shingles 5 years ago.
Check if she has hiv. But abx treatment has likely caused activation of the virus.
Treatment:
She is contagious (especially if - varicella naive individuals (never had chicken pox) are at risk of getting chicken pox. Side room whilst we assess her.
800mg aciclovir for 7 days.
Paracetamol/ dihydrocodeine for pain of the rash.
Call the on call microbiologist:
Contact trace for the other pregnant women she has come in contact with - must stay away.
Possible deep clean of where she sat in triage.
Assess in hospital away from neonates n pregnant women.
Safetynetting; come back to gp if resp symptoms or deterioration.
Postpartum:
Baby - Iv vzig?? (Likely not as not in last 5 days of pregnancy)
When is degeneration of a fibroid likely to occur and why?
Occurs in pregnancy because, thats when it outgrows its blood supply
In many gynae surgical proceedures, what suppositories can be given and why?
Diclofenac
Metronidazole - for abx properties
whirling appearnace on macroscopic examination is consistent with what finding?
leimyoma / fibroids
A 39 year old woman is having menorrhagia and dysmenorrhea. TVUS shows 2 large fibroids.
She has 1 child and opts for hysterectomy +BSO.
In the open surgery, the uterus is given to the medical student to dissect. On examination, before dissection only one fibroid can be seen.
what iis the explanation?
What are the considerations for this surgery?
explanation - 1 fibroid could easily be seen externally because it must have been a subserosal fibroid.
The other fibroid was seen upon dissection, it took up most of the uterine cavity, it musdt have been a submucosal fibroid - becuase these are the ones that really cause bleeding.
Both fibroids had whirling appearance, the emend/myometrium dont have this appearance.
considerations - the HBSO must be ovary sparing because dont want her going into early menopause.
What are the maternal risks of varicella in pregnancy?
Clinicians should be aware of the increased morbidity associated with varicella infection in adults, including pneumonia, hepatitis and encephalitis. Rarely, it may result in death.
You are prescribing aciclovir for a woman in pregnancy, what must you discuss with her?
Tell her It is not licences for use in pregnancy, used off label
But Discuss risks n benefits
Implications for foetus of maternal chicken pox infection? Rx?
Risk of FVS fetal viral syndrome?
Refer to fetal medicine specialist for detailed ultrasound at 16-20 weeks or 5week post infection. US will show:
limb deformity, microcephaly, hydrocephalus, soft tissue calcification and fetal growth restriction can be detected. A time lag of at least 5 weeks after the primary maternal infection is advised
do amniocentesis if mum lesions crusted. Then PCR of the amniotic fluid
Severe chickenpox is most likely to occur if the infant is born within 7 days of onset of the mother’s rash or if the mother develops the rash up to 7 days after delivery.52 For babies born to mothers who have had chickenpox within the period 7 days before to 7 days after delivery, it is therefore vital that the neonate receives prophylaxis as soon as possible with VZIG with or without aciclovir; there is no need to test in these circumstances.
Can mum with active chicken pox breastfeed?
Women with chickenpox should breastfeed if they wish to and are well enough to do so. If there are active chickenpox lesions close to the nipple, they should express breast milk from the affected breast until the lesions have crusted over. The expressed breast milk may be fed to the baby who is receiving treatment with VZIG and/or aciclovir.
How do cocps work in endometriosis?
Suppress HPO axis
This means less oestrogen and progesterone
This induces atrophy of ectopic growths
How do nsaids work in endometriosis?
How can they be taken?
Endometriosis deposits release prostaglandin, causing pain and inflammation
Nsaids inhibit pg synthesis reducing pain and inflammation
Take before periods commence if main conplaint is dysmenorrhea
How do gnrh agonists work in endometriosis? Benefits n side effects?
Suppresses HPO axis
So induces atrophy of ectopic deposits
Benefits: Very effective No side effects as of progesterones (weight gain etc) 3 monthly IM injections Hot flushes as profound e2 reduction
Negatives:
Less well tolerated than prog
Loss of BMD = cant use more than 6 months or in teens.
What are the indications for surgery in endometriosis?
Hormonal therapy poorly tolerated eg side effects
If young e.g. teen - hormone eg gnrh agonist unsuitable due to BMD reduction
Surgeon and patient determine when is best
What kinds of surgery are available for endometriosis?
Conservative surgical management:
Laparoscopy; Adhesiolysis and restoration of normal anatomy (helps in pain control)
Removal of endometriomas
Radical surgery:
hysterectomy + BSO and removal of deposits
- if no more kids wanted
