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.
