Gynaecology Flashcards
GTD
Rare 1: 714
High cure rate
EVAC
Aim to avoid medical management as can cause metastasis.
Cautious use of oxytocin as can lead to metastasis
TWIN pregnancy
- Referral to fetal medicine and trophoblastic screening centre
- invasive prenatal testing can be carried out
- Only 1:4 chance of achieving live birth following, risk of early fetal loss, PTD
FU
- if HCG normal within 56 days of pregnancy event then follow up for 6 months from date of evac
- If HCG not normal within 56 days then follow up for 6 months from date of normalisation.
- Need HCG levels monitoring 6-8 weeks following any future pregnancies to exclude disease recurrence.
FIGO scoring system to review if needs treatment with chemo.
If < 6 then for IM MTX and alt day folinic acid
If > 6 then multiagent chemo
1:80 will have a further molar pregnancy
If treated with chemo can have earlier menopause
Barrier methods until HCG normal
Can use hormonal methods after the HCG normal.
Not for IUD whilst HCG high as increased risk of perf
Endometrial hyperplasia - Without atypia
Irregular proliferation of the endometrial glands
Related to:
- High BMI
- Unopposed oestrogen
- PCOs / Anovulation with perimenopause
- granulosa cell tumours (oestrogen releasing)
- Oestrogen replacement / tamoxifen
Dx:
- Histology
- IF in a polyp then hysteroscopy should be undertaken for direct visualisation
- Risk of endometrial hyperplasia without atypia progressing to endo ca is < 5% over 20 years. Most will regress spontaneously and especially with RF addressed.
- Progesterone is regression is not spontaneous / abnormal bleeding
- LNG-IUS > POP ( norethisterone 10-15mg/day / medroxyprogesterone 10-20mg/day)
- Tx for 6/12
- 6/12 biopsy, minimum 2 biopsies negative prior to discharge.
- IF high risk ( raised BMI then consider yearly FU)
- IF persists for 12 months despite treatment risk of Ca is high and consideration for hysterectomy
HYSTERECTOMY
- if progresses to atypia
- No regression despite tx
- Relapse following completion of tx
- Declines local follow up / tx
Ablation not advised as can disrupt cavity and future sampling
Endometrial Hyperplasia - ATYPIA
- TAH as risk of progression to cancer
- TLH +/- BSO depending on age
- Risk of preexisting cancer 4%
- MDT
- LNG-IUS if wishing to preserve fertility
- Hysterectomy following completion of family due to risk of relapse
- 1:4 can achieve live birth with these fertility sparing methods
- Biopsies every 3 months until 2 consecutive negative samples
- long term follow up every 6-12 months if no bleeding symptoms
- Hysterectomy if no disease regression
- Early referral to subfertility services
- Assisted conception can be offered
- Regression of disease should occur prior
- If on HRT should have continuous combined or LNG-IUS i place
If polyp has endometrial hyperplasia focused in then removal may be adequate treatment.
Should have background surveillance of endometrium to decide on further management.
Ovarian cysts post menopausal women
Simple cysts <5cm have low RMI can be managed conservatively with repeat USS in 4-6 months.
Can discharge if unchanged / reduces in size with normal CA 125.
RMI < 200 should be suitable for laproscopic management
Any that are high liklihood for malignancy should be offered full staging laparotomy.
bladder pain
> 6 weeks typically void small volumes - cystoscopy is not diagnostic but needed to rule out other causes - Urodynamics if LUTS present - Dietary modification - Stress management - Analgesia - Amitriptyline or cimetidine - Pain clinic MDT > physio > pyschotherapy
Ectopic
20% fluid might be seen within the ovary - pseudosac.
If salpingotomy HCG level 7 days post op , then weekly until -ve.
MTX - hcg measured day 4, 7 if decrease by >15% can be measured weekly until <15
If not dropped then rpt USS ? rpt dose
- no effect on ovarian reserve
Chronic pelvic pain
intermittent / chronic lower abdo pain >6months. not exclusive to menstruation.
- hx
- px abuse
- pain diary
- function levels work / ADLS
- Offer trial of hormone treatment
- Antispasmodics in IBS
- Analgesia
FGM
Risk of prolonged labour, PPH, perineal trauma, LSCS
IN <18y must be reported to the police with 1 month
Should be inputted to the database - not anonymous unless published.
Not all should be reported in pregnancy unless at risk group
Offer referral for psych assessment, inf screen HIV, HEP
De-infibulation should be antenatally at 20 weeks if needed, first stage of labour or at delivery under LA, or post lscs
OHSS
Proinflammatory mediators - increased vascularity + prothrombotic reduced serum osmolarity and sodium. - fbc, u+e, osmolarity - pelvic USS - Usually within 7 days on HCG injection or > 10days due to HCG from early preg. - Hc pcos - breathlessness - oliguria - oedema - raised LFTs and reduced albumin - coag - CRP
- need to report to the fertility centre who completed tx
- avoid NSAIDS
- LMWH
- Usually self resolves
- Oral fluids
- Colloids > crystalloids
- Human albumin
- Consider anaesthetic input if cont haemoconcentration.
- Consider thrombosis if unusual neurological symptoms
- Pregnancies associated with OHSS may be increased risk of PET and Pre-term delivery.
Vault prolapse
McCall Culdoplasty at time of hysterectomy is preventative
- approximating the uterosacrals
Sacrospinous fixation at VH
Tx - open abdominal sacrocolpoplexy MESH
- Sacrospinous fixation
SSF not suitable in short vaginas or dysparaunia
Recurrent miscarriage
3 or more consequetive miscarriages
APS - most treatable cause
The effect of antiphospholipid antibodies on trophoblast function and complement activation is reversed by heparin.
And low dose aspirin
RF
- Maternal age
- Number of previous miscarriages
- Environmental factors - alcohol
- Obesity
- APLS
- Genetic - parental undiagnosed / embryo
- Anatomical - congenital uterine malformation / cervical weakness
- Endocrine - DM, thryoid , PCOS
- Infection
- Thrombophilia
Inx:
- 2 positive tests 12 weeks apart LUPUS ANTICOAGULANT / ANTICARDIOLIPIN ANTIBODIES
- Karyotyping
- USS
- Thrombophilia screen : Factor V liden, prothrombin and protien S
- With inhertited thrombophilias no evidence for heparin if 1st trimester losses but can in 2nd trimester losses
PMS
Symptoms cause impairment during the luteal phase of the menstrual cycle, abate during menstruation and then symtom free week.
Symptom diary over 2 menstrual cycles
GnRH analouges could be used if symptom diary is not conclusive
Tx
- CBT
- DROSPIRENONE (anti-androgenic progesterone containing COCP)
- continuous COCP
- Vagina progesterone / COC ring
- SSRIs
- Surgery - ( <45 then HRT add back)
Hyperemesis
with >5% pre-preg weight loss
Dehydration
Electrolyte imbalance
- metabolic hypochloraemic alkalosis
tx:
Cyclizine
Stemetil
Metoclopramide
Ondansatron
Corticosteroids
NaCL and KCL
MDT - dieticians / gastro / pyschlogists
Enternal / parenteral feeds E > P
If continued then growth scans
Vulval skin conditions
Lichen planus - mucous membranes. Inclusion of the vagina excludes lichen sclerosis. Screen for autoimmune disease - steroids topical and vaginal - oral ciclosporin - retinoids - oral steroids - biologics
Lichen simplex can be associated with low iron
vuvlval psoriasis - well demarcated brightly erythematous plaques - symetrical - natal cleft tx - steroids - coal-tar - Vit-D Talcalcitol
VIN
- Most commonly caused by HPV 16
- Or in relation to lichen sclerosis / lichen planus
Risk of progression to SCC with diffirenciated VIN
raised white, erythematous , pigmented lesions, warty , moist , eroded.
Ensure cervical cytology up to date
All patients with VIN should be reffferred to colposcopy to exclude VIN / CIN if anal lesions then refer for anoscopy
tx - local excision, imiquimod cream, surgery.
Menopause
SSRIs not suitable for women with breast ca who are taking tamoxifen
VTE higher with oral than topical preparations
transdermal no greater than baseline population risk
better in patients with high BMI
POI
Women <40 with menopausal symptoms or infrequent periods
FSH raised on 2 samples 4-6 weeks apart
- HRT / COCP
- continue until menopausal age
- HRT not contraceptive
INCONTINENCE
INX
- Urine dip ( blood / infection )
- Bladder scan
- Bladder diary
urodynamic for SUI if
- Urge predominant / mixed / unclear
- symptoms of voiding dysfunction
- anterior / apical prolapse
- Px SUI surgery
Mx
- dietary modifications
- weight loss
- PFE
- bladder training
OAB - ANTIMUSCARINIC oxybutynin tolteridine darifenicin / solifenacin - B3 Agonist Mirabegron - DESMOPRESSIN caution in >65, HF, HTN
Vaginal oestrogens
- offer urodynamics if non-responsive + see if detrusor overactivity
- if DO then surgery if not MDT
- BOTOX
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty
- urinary diversion
SUI
- Open or closed colposuspension
- Autologous rectus fascial sling
- Intramural bulking agents
- Duloxetine medication
PROLAPSE
Stage 1/2 - PFE
PESSARIES
UTERINE
- vaginal hysterectomy +/- SSF
- vaginal hysteropexy
vault prolapse
- SSF
- Sacrocolpoplexy
HMB
FBC
Coag if longstanding / FH
Can offer treatment without inx if history / examination low risk for fibroids / cavity abnormality / hist abnormality or adenomyosis
- Hysteroscopy if considering above
Pelvis USS if considering fibroids / inconclusive examination
Adenomyosis
- significant dysmenorrhoea
- bulky tender uterus
Mx
- Mirena
- TXA , NSAIDS
- COCP, POP
Fibroids
- offer ullipristal acetate
- UAE
- Surgery
Fertility
- Intercourse every 2-3 days
- Alcohol / smoking / BMI < 30 or <19 with amenorrhoea
- Hosp referral if 1 year no conception / 6 months of IUI
- Earlier if >36, known factor
Semen analysis
- rpt 3 months if abnormal
- straight away if severe
HIV
- Male to female transmission is low when
- Compliant with HAART
- viral load < 50 for > 6months
- UPI restricted to ovulation times
If not compliant with above then offer sperm washing
Offer Hep B vaccination if partner positive prior to starting treatment
Rubella
- Offer vacination
- No pregnancy 1 month following
IVF if 2 years of unexplained
IUI if not concieved after 6 cycles then further 6 if normal inx
Donor insemination
- If no conception after 3 months should be offered assessment for tubal damage
- If not successful after 6 months with regular ovulation then offer donor insemination and ovulation induction
Cryopreservation initial period of 10 years
Potentially a small increased risk of borderline ovarian tumours with IVF / ICSI
Endometriosis
Examination
TVS
MRI - If need to assess for deep pelvic endo with organ involvement
Diagnostic lap consider imaging prior if deep disease potential
In Patients with retrovaginal pain refractory to other treatments consider aromatase inhibitors + contraceptives ( Letrozole) as they reduce endometriosis associated pain
Can use oxidised regenerated cellulose during operative laparoscopy for endometriosis as it reduces adhesion formation
LASER > MONOPLOAR in treatment for women with endo and infertility as has higher spontaneous success rates
No evidence cystectomy prior to ART improves pregnancy rates only remove if causing pain or for access to follicles
Should avoid unopposed oestrogen in postmenopausal women after hysterectomy but balance with increased systemics risks involved with combined.
POI
Loss of ovarian function before 40
Raised gonadotrophins and low oestrogen
If patient attends with oligomenorrhoea or amenorrhoea then should enquire about symptoms of oestrogen deficiency.
Dx:
Oligo /amenorrhoea for at least 4 months
FSH > 25 > 4 weeks apart
- Chromosomal analysis
- Godadectomy if women have detectable Y chromosomal material
- Fragile X
21OH-ab or adrenocortical antibodies in women with POI of unknown cause + thryoid AB
Could potentially be as result of surgery
Smoking
Cardiovascular disease
- stop smoking, weight loss, exercise
Chance of spontaneous pregnancy
Bone health - need oestrogen replacement HRT > COCP
BMD with DEXA scan
Previous history of VTE then should be reffered to haem prior to starting HRT .
Transdermal is the best option in women with POI requiring HRT who are obese or over weight
ANC
Combined test - ( NT, bHCG, PAPP-A) 11-13+6 NT - < 3.5 QUAD 15-20 High risk 1:150 cfDNA from 10
Placenta praevia
Rpt USS at 32 weeks
Most cases 90% resolve by term , rpt USS if still low lying at 32 rpt 36.
Shortened cervical length may predict risk of emergency LSCS due to MOH
steroids 34 - 35+6
Delivery from 34 weeks if vaginal bleeding , uncomplicated 36-37
Consider USS guided incision at LSCS to avoid the placenta.
If transected during LSCS then immediately clamp cord
Bakri likely to fail if >500ml in first hour of insertion
Placenta Accreta
If LSCS and anterior placenta low lying then for specialist USS
Delivery between 35-36+6 weeks
If expecting significant blood loss / LSCS hysterectomy then deliver between 34-35 weeks
- Consultant obs
- Consultant anaes
- Blood and blood products
- MDT
- Consent of options ( hysterectomy, placenta left in situ, cell salvage, interventional radiology)
- Critical care bed
- Cesarean hysterectomy leaving the placenta in situ is preferable to trying to remove it from the uterine wall.
- Can consider uterine preserving surgery if confined to small area and not deep inflitration
- Expectant management with regular review a possibility if uterine preservation required
VASA PRAEVIA
- delivery between 34-36 week
- steroids from 32
IOL
Offer in uncomplicated pregnancies between 41-42 weeks
If declines after 42 weeks then should have bi-weekly CTG, LV checks
Can offer with breech if declines ecv and lscs
severe FGR with compromise then IOL not reccomended
Intrapartum care
low risk multip similar risk home birth / BC / DS
4 more / 1000 of serious risk to baby at home vs hosp with primip
rupture of membranes
serious infection risk 1% rather than 0.5 intact
GBS
If previous GBS then can offer testing at 35-37 weeks , testing should be 3-5 weeks before estimated delivery.
AB if px baby affected by GBS
Maternal request testing is not offered
If GBS and SROM with planned LSCS offer IPAB whilst awaiting LSCS
if temp >38 with or without GBS should be offered IPAB
which cover GBS
Give IPAB to all women in preterm labour to cover GBS
In PPROM delivery not indicated under 34 weeks unless evidence of infection
BREECH
Factors increasing risk:
- hyperextension of neck on USS
- EFW > 3.8kg
- EFW < 10th centile
- Footing breech
- antenatal fetal compromise
Labour:
- adequate descent is required prior to encouragement of active second stage - until visible
- Amniotomy only if definitive indication not for slow progress - consider LSCS
- Passive second stage, if not visible after 2 hours then consideration of LSCS
Intervention if evidence of poor condition, delay >5mins from buttocks - head. >3mins umbilicus to head
cervical incisions 2, 10 and 6
VTE
If doppler negative but high clinical suspicion then rpt USS on day 3 and 7
PE - ECG and CXR
If abnormal CXR then CTPA > V/Q scan
T wave inversion S1, Q3, T3
IVC filter peripartum for patients with iliac vein VTE to reduce the risk of PE or recurrent PE despite tx
fondaparinux if unable to tollerate LMWH due to HIT
If patient on therapeutic doses of LMWH consideration of wound drains
VBAC
1: 200 risk of rupture , INCREASED X2/3 if induced
sucess 75% no previous VD
85-90% if previous VD
Increased risk of rupture
- <12month inter delivery
- post date pregnancy
- age >40
- obesity
- lower pre-labour bishop score
- macrosomia
- thin lower segment
Dx
- abnormal CTG
- abdo pain
- scar tenderness
- abnormal vaginal bleeding
- stopped contractions
- loss of station of pp
Shoulder dystocia
PPH 11%
3/4 TEAR 4%
VAGINAL LAC
Brachial plexus injury 2-16%, < 10% have permenent injury
humeral / clavical fractures
Hypoxic brain injury
risk factors - px shoulder dystocia , risk increased x 10% - macrosomia > 4.5kg dm bmi > 30 IOL
- prolonged 1st stage / 2nd
- secondary arrest
- syntocinon
- OVD
suprapubic pressure reduces the bisacromial diameter and roates shoulders into the wider oblique diameter.
RFM
RF for SB
- multiple consultations for RFM
- FGR
- HTN
- DM
- Maternal age
- primip
- smoking
- placental insufficiency
PPH
Minor 500-1000ml
Major (moderate) > 1000
> 2000 severe
measure fibrinogen keep > 2
PT / APTT should be less than x1.5 of normal
FFP if suspected coagulopathy
if fibrinogen low then needs cryoprecipitate / fibrinogen
PLT if < 75
OASIS
RF:
Asian ethnicity Primip 4kg Shoulder dystocia OP Prolonged second stage OVD
- slow fetal head
- support periunium
PR!
Separate repair of the IAS
Subsequent tear is 5-7%
17% Worsening faecal symptoms after a second vaginal delivery
OVD
OUTLET - visible without separating labia
LOW - + 2 or more not visible
MID - above + 2
Failure associated with:
- High BMI
- 4kg
- OP
- mid cavity
SEPSIS
- BLOOD CULTURES
- URINE OUTPUT
- FLUIDS
- ANTIBIOTICS
- LACTATE
- OXYGEN
IVIG can be given in cases where severe infection is present
URETERS
From renal pelvis, down the psoas muscle to pelvic brim where they pass over common iliac vessels.
- Here can be damaged ligating the ovarian vessels
Pass down pelvis side wall and under uterine arteries. They are lateral to cervix here and can be most commonly damaged during clamp and cutting of the cardinal and uterine arteries.
Then run into back of the bladder into trigone, can be damaged anterior to vagina during closing of vaginal cuff.
