Gynaecology Flashcards
Define Pelvic Inflammatory Disease (PID)
Acute community acquired spectrum of infections of the female upper genital tract
What are the risk factors for PID?
- Early sexual debut
- Age <25yr / Low parity
- Sexual promiscuity
- Sex during menstruation
- Current Infection
- Poor socioeconomic circumstances
What are the classical symptoms of PID?
- Lower abdominal pain
- Cervical excitation tenderness
- Adnexal/uterine tenderness
How do you classify PID?
Gainsville classification
What is Gainsville stage I PID?
- Vaginal discharge
- Signs of infection
- Local tenderness
e.g. Early salpingitis with local adnexal tenderness
What is the treatment of Gainsville stage I PID?
Outpatient antibiotics PO
- Ceftriaxone 250mg IM stat
- Azithromycin 1g PO single dose (doxycycline 100mg PO BD x14)
- Metronidazole 400mg PO BD x7d (x14)
Goal: Eliminate symptoms and infectivity
What is Gainsville stage II PID?
- Vaginal discharge
- Signs of infection
- Local tenderness / CET
- Pelvic peritonitis
e.g. Late salpingitis with localized pelvic peritonitis
What is the treatment of Gainsville stage II PID?
Inpatient admission care and parental AB’s
- IV fluids
- Analgesia
- Monitoring
- IV ABs
- Ceftriaxone 1g IV OD
- Metronidazole 500mg IV 8hrly
- Follow with co-amoxiclav 1g PO BD
Goal: Preservation of Fallopian tubes
What is Gainsville stage III PID?
- Vaginal discharge
- Signs of infection
- Local tenderness / CET
- Pelvic peritonitis
- Pelvic mass
e.g. Tubo-ovarian mass; tubal occlusion
What is the treatment of Gainsville stage III PID?
Inpatient admission care and parental AB’s
- IV fluids
- Analgesia
- Monitoring
- IV ABs
- Ampicillin 1g IV 6hrly
- Metronidazole 500mg IV 8hrly
- Gentamycin 240mg OD
- ? Surgery
Goal: Preservation of ovarian function
What is Gainsville stage IV PID?
Stage III + Generalised peritonitis
e.g. Ruptured tubo-ovarian cyst/abscess
What is the treatment of Gainsville stage IV PID?
Laparotomy and triple ABs therapy
What are the indications for admission of a patient with PID?
- Pregnancy
- Temp > 38
- Failure to respond to ABs within 48 hrs
- Peritonitis
What are the indications for a laparotomy for a patient with PID?
- Generalized periotonitis
- Tubo-ovarian cyst/abscess not responding within 48 hrs
- Uncertain diagnosis
- Patient >40yrs
- Recurrent PID
- History of tubal ligation
How would you know a patient is responding to therapy in PID?
- Resolution of symptoms
- Reduction in temperature
- U/S changes - decrease in size
What are the complications of PID?
- Recurrent PID
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
What is the DDx for PID?
- Ectopic pregnancy
- Dysmennorhoea
- Ovarian torsion - ovary/cyst/tumour
- Endometriosis
- Appendicitis
- Cholecystitis
- Constipation
Define abnormal uterine bleeding (AUB)
The change in frequency, duration or volume or menstrual flow such as;
- Bleeding between periods
- Bleeding after coitus
- Spotting anytime during the menstrual cycle
- Bleeding heavier or longer than usual
- Bleeding after menopause
What is the classification of AUB?
Ovulatory:
- Typically cyclic heavy and prolonged
- Due to anatomic of physical lesion
- Haemostatic defect, infection, trauma
Anovulatory:
- Abnormality of hypothalmic-pituitary axis
- Bleeding from the endometrium that has nor been proceeded by ovulation
- Most common cause of AUB
- Irregular + prolonged + heavy
What are the causes of AUB in a non-pregnant woman?
PALM COIEN
- Polyps
- Adenomyosis
- Leiomyomas
- Malignancy
- Coagulopathies
- Ovarian dysfunction
- Iatrogenic
- Endometriosis
- Not yet defined
What are the causes of AUB in a pregnant woman?
- Ectopic pregnancy
- Miscarriage
- Gestational trophoblastic disease
What special investigations would you do on a patient with AUB?
- Cervical cytology - Suspicious? -> Biopsy
- Pregnancy Test
- FBC, U&E, Clotting profile
- Transvaginal U/S
- Endometrial biopsy
- Hysteroscopy
How do you diagnose Polycystic Ovarian Syndrome (PCOS)?
Rotterdam Criteria
- Anovulation/Oligomenorrhoea for at least 6 months
- Biochemical and/ clinical signs of hyperandrogenism
- Polycystic ovaries on U/S
OR
Androgen Excess Society Criteria
- Ovulatory & menstrual dysfunction
- Hyperandrogenism
- Hirsutism, acne and androgenic alopecia
- Polycystic ovaries
Define oligomenorrhoea/anovulation
- <8 cycles per year
- Cycles lasting <26 days
- Cycles lasting >35 days
Provide a DDx for PCOS
- Premature ovarian failure
- Ovarian neoplasm
- Hypothalmic/pituitary dysfunction
- Hyperprolactonaemia
- Thyroid dysfunction
- Steriods
What are the signs of Hyperandrogenism?
Non-virilising
- Hirsutism
- Acne
- Infertility
Virilising
- Male pattern balding
- Deep voice
- Masculine habitus
- Clitoromegaly
What is the management of PCOS?
- Exclude other causes
- Ovulation induction
- Weight loss
- Anti-eostrogen (Clomiphene citrate) + Dexamethasone
- Aromatse inhibitor (Arimidex) - to decrease peripheral conversion of eostrogens
- Insulin sensitisers (metformin)
- When other treatments fail - GnHR therapy / Ovarian drilling
- Fertility treatments
- IVF
- Stop anti-androgen and insulin sensitiser
- Preventative therapy
- Treat DM / Hyperlipdaemia / Endometrial hyperplasia
What is the typical presentation of a patient with PCOS
- Overweight
- Young female
- Infertility
- Abnormal menstrual bleeding
- Hyperandrogenism
- Metabolic syndrome
What are the metabolic problems associated with PCOS?
- Obesity
- DM
- Hyperlipdaemia
- Impaired glucose tolerance
Define Post-menopausal bleeding (PMB)
Bleeding from the female genital tract in an appropriately aged woman not using hormonal therapy at 6 months after cessation of menstruation
