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
What are the causes of PMB?
Local
- Vaginal trauma/polyps
- Atrophic vaginitis
- Cervical trauma/polyps
- Endometrial polyps/atrophy
- Malignancy of the gential tract
- Endometrial hyperplasia
Systemic
- Bleeding disorders
- Exogenous oestrogen - hormonal treatment
- Endogenous oestrogen - obesity
What the most common causes of PMB?
- Endometrial atrophy
- Polyps
- Endometrial Ca
- Endometrial hyperplasia
- Hormonal effects
How would you investigate a woman with PMB?
- Urine analysis and culture
- FBC, U&E, Coagulation (INR, PTT), LFT
- Cervical cytology / biopsy / colposcopy
- Uterine evaluation - TVUS, Endometrial biopsy, Hysteroscopy
How would you manage a patient with PMB?
Management depends on cause
- Endometrial atrophy
- No treatment, investigate if recurrent
- Vaginal atrophy
- Topical oestrogen cream
- Cervical/Endometrial polyps
- Hysteroscopic resection
- Endometrial hyperplasia without atypia
- progesterone therapy
- Endometrial hyperplasia with atypia
- Surgery - TAH + BSO
- Endometrial Ca
- Surgery - TAH + BSO
- Stage dependent chemo/radio
- Cervical Ca
- Surgery + chemoradiation
- Fibroids
- Single - Submucosal hyteroscopic resection
- Multiple - TAH
What are the risk factors for Endometrial Ca?
- Obesity - peripheral conversion of androgens to oestrogens
- Late menopause
- DM
- Cancer - ovarian, breast, colon
- Nulliparity
- Tamoxifen use
What is the DDx for leimyomata (Fibroids)?
- Pregnancy
- Maligancy
- Infectious mass - TB
- Adenomyosis
- Endometriosis
- Bladder mass
How would a patient with leimyomata present?
- Infertility - most common
- Vaginal bleeding - menhorrhagic
- Pain - secondary to infection
- Abdominal mass
- Vaginal discharge - secondary to infection
- Uterine inversion
What is the management of a patient with leimyomata?
Conservative
- For asymptomatic single/small
- Leave alone during pregnancy
- 3 monthly follow-ups
- GnRH- analogues -
- Progesterone receptor modulators - Mifepristone
Non-invasive surgery
- Uterine artery embolisation
- Magnetic resonance-guided focused U/S surgery
Surgery
- TAH (large/multiple)
- TVH (small)
- Myomectomy (if fertility is desired)
What are the complications of fibroids?
Non-pregnant
- Anaemia
- PID
- Torsion
- Ascites
Pregnant
- Miscarriage
- Abruptio placenta
- PPROM
- Preterm labour
What are the indications for surgery in a patient with leimyomata?
- Fibroid larger than uterus (>14 weeks)
- Distorsion of uterine cavity
- In the lower part of uterus
- Uncertainty of the nature
- Presence of complications
- Sudden enlargment
Define Infertility
The inability to conceive after 1 year of unprotected regular intercourse in persons <35 years
What is the difference between primary and secondary infertility?
Primary - Never conceived
Secondary - At least one previous pregnancy prior to infertility
What blood tests need to be done in a female with infertility?
- FSH, LH, D3
- TSH, prolactin
- HIV
- VDRL
- Day 21 progesterone
What investigations need to be done in female with infertility?
- Pelvic U/S
- Hystosalpingostomy to rule out tubal factors
- Hysteroscopy
- Laproscopy
What blood tests need to be done in a male with infertility?
- HIV
- VDRL
What investigations need to be done in a male with infertility?
Semen analysis after 2-3 days of abstinence
What are the normal parameters of a semen analysis?
Total sperm count >15 million
Motility >30%
Morphology >5% normal
Volume >1.5ml
What are the treatment options for infertility?
- Ovulation induction
- Artificial insemination
- IVF
- Intracytoplasmic sperm injection (ICSI)
Define a miscarriage
Ending of a pregnancy before the fetus is viable - 27 weeks GA or 750g
How is miscarriage classified?
- Duration
- First trimester
- Second trimester
- Type
- Spontaneous
- Induced
- Clinical
- Complete
- Incomplete
- Threatened
- Inevitable
- Missed
- Septic
What are the causes of a spontaneous miscarriage?
- Early
- Chance
- Poor placentation
- Late
- Incompetent cervix
- Poor placentation
- Infections
What are the causes of recurrent miscarriage
- Genetic
- Structural abnormalities
- Infection
- Antiphospholipid syndrome
- Thrombophilic disorders
What are the classifications of contraception?
- Natural methods
- Barrier methods
- Hormonal contraception
- Inter-uterine contraceptive devices (IUCD)
- Emergency contraception
- Surgical methods
What are the types of IUCD
- Mirena
- Lasts 5 years
- Slow release levongesterol
- Copper IUCD
- Lasts 10 years
- Non-hormonal
What are the hormonal types of contraception?
- Oral contraceptive pill
- Progesterone injection
- Implanon
What are the emergency forms of contraception?
- Combine oral contraceptive
- Progesterone only pill
- Copper IUCD
What are the advantages of the Copper IUCD?
- Safe and immediately effective
- Non-hormonal - no hormonal side-effects
- Fertility is immediately restored
- Its long lasting
- Good compliance - no pills to remember
- It can be used as an emergency contraceptive
What happens if you missed a pill of COC?
Week 1 - Consider emergency contraception
Week 2 - Take as soon as possible OR Take 2 the following day OR if 2 missed then take 2 each of the following 2 days OR of >3 missed then start a new pack
Week 3 - Restart a new package at active pills
Week 4 - Continue from the current days pill (placebo)
Management of “lost strings” (IUCD)
- Causes
- Expulsion
- Pregnancy
- Moved up in uterus
- Perforation
- Approach
- Pregnancy test
- Uterine sound with AXR
- Ultrasound
- Removal
- Thin forceps removal
- Special hook removal
- Hysteroscopy
- Laparotomy/laproscopic if perforated
Management of Cervical polyp found on examination
- Not regarded as a true neoplasm, but as the result of hypertrophy of endocervical tissue – epithelium and stroma. Usually at transformation zone
- Often found with infection
- 40-60 year old females, multigravidae
- May be asymptomatic or have PV discharge (due to infection) or PV bleeding
- Size can vary from mm’s to cm’s
- Can be multiple or single
- May have narrow pedicle or broader base
- Can undergo squamous metaplasia
- Can be removed by twisting it off using a Bonney’s polyp forceps or excised.
- Specimen should always go for histological examination
Risk factors for cervical ca
HIV
HPV 16 and 18
What is the management of a suspicious cervical lesion?
CIN I (LSIL)
- HIV (-) Follow up and cytology
- HIV (+) Colposcopy and cone biopsy
CIN II & CIN III & CIS (HSIL)
- Colposcopy and LLETZ
- TAH/Vaginal hysterectomy (if completed family)
Stage I-IIa Cervical ca
- Simple/radical hyterectomy
Stage IIb- IV Cervical ca
- Radiotherapy
- Chemotherapy
Causes of post-op sepsis?
- Day 2-3 : Chest infections, atelectasis
- Day 3-7 : Chest infection, wound infection, UTI
- Day >7: DVT, PE
Risk factors for post-op sepsis?
- HIV
- DM
- Obesity
- Excessive blood loss
- Bacterial vaginosis
Symptoms of post-op sepsis?
- Fever
- Tachycardia
- Post-op general complaints - Pain
Treatment of post-op sepsis?
- Localised
- Ceftriaxone 2g stat, and then 1g OD
- Extensive infection
- Clindamycin 900mg IV 8hly
- Gantamycin 5mg/kg IV OD
- Vancomycin (if enterococci suspected)
Define the different types of urinary incontinence
Stress incontinence - involuntary leakage of urine on effort or exertion such as sneezing
Urge incontinence - involuntary leakage of urine precede by urgency
Overflow incontinence - involuntary leakage of urine due to inability to tell when the bladder is full
Mixed incontinence - involuntary leakage of urine due to urgency and stress
True incontinence - Presence of a fistula causing leakage
What is the treatment of stress incontinence?
- Conservative
- Lifestyle intervention (LOW, smoking cessation, relief of strenuous exercise)
- Physical therapy (pelvic floor muscle training, intra-vaginal weighted cones)
- Pads
- Clean intermittent self-catheterisation
- Medical
- Duloxetine (SNRI) – increases sphinchteric muscle activity
- Surgical
- Burch colposuspension
- Synthetic mid-urethral sling*
What is the treatment of urge incontinence?
- Exclude
- Cystitis
- DM
- Pelvic organ prolapse
- Conservative
- Pelvic Floor Muscle exercises
- Reduction of caffeine and alcohol
- Adequate daily fluid intake
- Bladder retraining (regularly timed voids, gradually lengthening voiding intervals)
- Medical
- Anticholinergics* (Oxybutenin)
- Surgical (Only as last resort)
- Botulinum toxin
- Neuromodulation
- Urinary diversion
Indication for a vaginal pessary
- Frail elderly whose medical condition precludes surgery
- Symptomatic relief while waiting for surgery
- Treatment of prolapse in early pregnancy
- Alternative to surgery if child-bearing incomplete
- Diagnostically to see if symptoms relieved
- Management of decubitous ulcer prior to surgery
Define menopause
The permanent cessation of menstruation resulting in loss of ovarian follicular function, determined retrospectively after 12 months of amenorrhoea.
Symptoms of menopause?
- Amenorrhoea
- Hot flushes
- Insomnia
- Mood changes
- Irritability
- Poor memory
- Skin thinning
- Vaginal atrophy
- Loss of libido
- CVA
- Hisuitism
- Osteoporosis
- What is the treatment of menopause (HRT)?
(Opposed oestrogen is used when the uterus is still present)
- Cyclic oestrogen – (+) withdrawal bleeds
- Sequential (progesterone added for 10-14 days p/month)
- CCEPT – (-) withdrawal bleeds
- Gonadomimetics
Contraindication for HRT
- Cardiovascular disease
- Hypertension
- Diabetes
- DVT risk
- Previous breast ca
- Smoking
What are the advantages of oestrogen-replacement therapy
- Decreased vasomotor symptoms
- Decreased depressive symptoms
- Improved quality of life
- Improved urogenital symptoms
- Decreased osteoporosis
- Decreased cardiovascular disease
