Gyne Flashcards
What are the indications to admit a patient with a diagnosis of PID (7)?
Severe illness
Tubo-ovarian abscess
Cannot r/o other surgical emergency
Unable to take oral meds
Not responding to PO meds
Pregnancy
Non-reliable
What are the predictors of endometrial ablation failure (3)
Age < 40
Prior tubal ligation
Preoperative dysmenorrhea
What is the average age at diagosis of LMS
52
What is the change of concomittent endometrial cancer when hyperplasia with atypia is present
17 - 25 %
What causes endometrial implants to be so hyper-estrogenic?
Implants express:
- Aromatase
- 17 beta hydroxysteroid dehydrogenase type 1
- All genes required in the stereogenesis cascade to make estradiol from cholesterol
Implants lack
- 17 beta hydroxysteroid dehydrogenase type 2 (inactivates estrogens)
What is the most common adverse event following non- resectoscopic EA?
Pelvic pain
Cramping
Nausea/ vomiting
Resolve within 24h
What is the DDx of a black vulvar lesion?
Lentigo
Nevus
Vitiligo
Cherry Hemangioma
Melanosis
Sebrroric keratosis
Melanoma
VIN / Vulvar cancer
BCC
Should you give abx for cardiac patients to prevent endocarditis?
Not for GU procedures
If high risk pts and receiving abx for something else, should consider using Abx that will also cover enterococci
What is the % of patient requiring a hysterectomy within 10 years of a myomectomy
10 %
What is the risk of PPH in patient with vWD/ Facto XI/ hemophilia carriers
16 - 22 %
Normal population 4-5 %
What are potential test that may aid in LMS pre-op dx
MRI
Serum LDH
Endometrial biopsy
Name the side effects of progesterone (4)?
Acne
GI Upset
Edema
Weight gain
Irregular menstrual bleeding
What is the risk of occult sarcoma at time of fibroid surgery
1/350 - 1/2000
What ovary torts more frequently?
(#341)
Right ovary
(sigmoid?)
What is the incidence of vault prolapse post hysterectomy in patient with no evidence of POP
1-2 %
What is the most common cause of secondary dysmenorrhea?
Name other causes of secondary dysmenorrha (5)
The most common cause: Endometrioisis
Other causes:
Adenomyosis
Uterine myomas
Cervical stenosis
Obstructive lesions of the genital tract
Define primary dysmenorrhea (#345)
Menstrual pain in the absence of pelvic pathology
What is the inheritence pattern of vWD
About GnRH agonists for AUB,
1- What is the expected % schrinkage of fibroids
2- When is the greatest effect apparent
50 % decrease in initial volume
Greatest effect after 12 weeks
What progesterone and what dose is released daily with a Mirena ?
Levonorgestrel
20 ug/ day
What is the angle of knee abduction recommended in gyne surgery ?
< 90 degrees
What is the typical apparence of endometriotic lesions in adolescents?
Clear vesicles
Red lesions
vs: classic powder burn lesions
At what weight should you adjust pr-op abx?
120 kg
Previously BMI > 35
At what deficit should you abort a ablative procedure ?
For both types of media
Non conductive solutions : 1500 mL
(Glycine, mannitor, sorbitol, cystosol)
Conductive solutions: 2500 mL
(NS)
What is the mechanism of action of Desmopressin (DDAVP) for vWD
Releases vWF from storage sites within endothelial cells
–> increases vWF
–> increase plasma levels of factor 8
What are the alternative regiment for Abx prophylaxis in gyne surgery?
Clinda 600 mg IV
Erythro 500 mg IV
Flagyl 500 mg IV (?) - Dose not specified
What are the options to treat breakthrough bleeding (in patients w vWD)?
Double COC pill for 3-4 days
Add a 50 ug estrogen patch for 3-4 days
Change to a 50 ug pill
What are the anti-androgenic progestins
Norethedrone (NETA)
Drosperinone
Desogestrol
What are the types of vWD
Type 1 : partial quantitative reduction in VWF
Type 2: qualitative deficiency of VWF
Type 3: absence of VWF
What are the absolute contraindications to endometrial ablation (5)?
Pregnancy
Desire to preserve fertility
Endometrial cancer or hyperplasia
Cervical cancer
Pelvic infection
What is the most common cause of secondary dysmenorrhea in adolescents?
Endometriosis
What are the mechanism of fluid overload in hysteroscopy (3)?
Absorption across the endometrium
Intravasation through surgically opened venous channels
Spill from fallopian tubes with absorption by peritoneum
Name the RF for LMS (7)
(# 371)
Age > 50
Black race
Tamoxifen use
Previous pelvic radiation
Hereditary leiomyomatosis
Hx of hereditary retinoblastoma
Renal cell carcinoma
Are Abx recommended for HSG?
Only if tubes are dilated (doxy)
Are GnRH agonists linked to decreased bone mineral density
Yes (especially if used long term)
Is ablative or excisional treatment better for pain management in endometriosis?
No difference for pain (or fertility treatment)
List the 4 criteria for endometriosis and epithelial ovarian cancer
Presence of both endometriosis and malignancy within the same ovary
Carcinoma must arise from the endometriosis and not invade from another source
Specimen must contain histological characteristics of endometriosis including stroma and glands
There must be morphological continuation between benign and malignant epithelium within the endometriosis
What is the treatment of choice for severe vWD?
How long does it last?
Humate P
Viral inactivated, pooled human plasma concentrate containing factor 8 and vWF
Replaces vWF for 12 - 24 h
(FFP and Cryo only when Humate P is not available)
Does hysterectomy alone affect ovarian reserve?
YES
2-fold increased risk of ovarian failure
> 20 % pts have symptoms of decreased ovarian reserve within 1y
Decrease AMH shown in studies
What are the risk factors for fluid overload (4)?
Use of hypotonic solutions (vs isotonic)
Long procedures
High distension pressure
Resection of large pieces of tissue
What are the options for treatment of acute hemorrhage post endometrial ablation (3)
AFTER r/o Uterine perforation:
Foley ballloon tamponade
Intracervical vasopressors injections
Misoprostol PR
What are potential complications of pregnancy following endometrial ablation (3)?
Uterine rupture
Limb defects
Premature labour
What is the rate of fibroid recurrence after myomectomy
15 %
Which treatment for endometriosis causes bone loss?
GnRH agonists
Depot-progestins
What is the preferred regimen of Abx for a therapeutic abortion?
Doxycycline
100 mg PO pre-procedure
200 mg PO post-procedure
What method of hysterectomy has the lowest post-op morbidity or complication rate
Vaginal
Name the investigations required before an endometrial ablation
Pregnancy test
PAP test within 2 years
EMB
Assessment of uterine cavity for Mullerian anomalies or intercavitary pathologies (TVUS, hysteroscopy, contrast sonography)
Cervical cultures PRN
What epithelial cancer is linked to endometriosis?
Clear cell cancer (35%)
Endometrioid (20%)
How do factor 8 (VIII) and vWF evolve in pregnancy ?
They increase in pregnancy
Reach their maximum between 29 - 35 weeks
Return to baseline 7-10 days post delivery
Remove epidural catheter directly PP as factors are the highest
After how many weeks can we assess the efficacy of endometrial ablation
6 - 12 weeks post op
What is the first line therapy in patient with late PPH and vWD
Cyklokapron + OCP
Can start prophylactic OCP immediatly PP and for 1 month
What is the inheritence pattern of Hemophilia A and B
Both X linked
Hemophilia A (Factor 8 deficiency)
Hemophilia B (Factor 9 deficiency)
Are antibiotics recommended before endometrial ablation?
No
What are the criteria to observe vs operate an endometrioma?
Asymptomatic
Small endometrioma with classic findings
Established diagnosis of endometriosis
Stable Ca125
When should you supress ovarian function in women with endometriosis and infertility?
Patient who undergo IVF
(GnRH agonist x 3-6 mo)
Not effective for
- mild to moderate disease
- pre-op surgery for endometriosis
Which of the 2 medications have a shorter time to ammenorrhea - GnRHa vs Ulipristal
Ulipristal (7 vs 21 days)
What is the ideal technique to remove superficial endometriosis for fertility purposes?
No difference in terms of fertility
Excision = ablation
Electrocautery = laser
What should be added to GnRH agonist for treatment of endo in adolescents (3)?
Add back therapy
Calcium
Vitamin D
What can decrease vWF levels (2)?
Hypothyroidism
Blood type 0 lower than type non-O
Describe von Willebrand studies
Factor VIII
vWF antigen
vWF functional assay
What are the most common adverse events in resectoscopic ablation (4)?
Uterine perforation
Fluid overload
Hematometra
Cervical lacerations
What is the first line treament of menorrhagia in patient with bleeding disorders ?
COCs
What is the inheritence pattern of vWD?
Autosomal dominant (Type 1 and some type 2)
Autosomal recessive (some type 2 and type 3)
After how long off GnRH agonist treatment are fibroids expected to regrow?
What is the maximum length of continuous tx
12 weeks
3-6 months
Name the contraindications to non-resectoscope EA (2)?
Classical CS
Transmural myomectomies
(Caution if > 2 CS)
What are the indications for laparoscopy in endo patients with infertility?
1- Deep dyspareunia, severe dysmenorrhea, dyschezia
2- Tender nodules on uterosacrals
3- Persistent adnexal mass (remove endometrioma if diameter > 3 cm)
What are the advantages of pre-treating the endometrium in resectoscopic EA (3)?
Higher short term amenorrhea
Decreased fluid absorption
Shorter operative times
(Better visualization)
What are the 3 indications for surgical management of TOA?
Intra-abdominal TOA rupture
Failure to respond to ABX within 48-72h
Suspicion of other surgical emergencies (ex appy)
What can increase vWF levels (8)?
Age
DM
Malignancy
Stress, exercice
Oral contraceptive
Pregnancy
Inflammation (acute or chronic)
Hyper thyroidism
Name the effects of decreased estrogen exposure (5)
Hot flushes
Insomnia
reduced libido
vaginal dryness
headaches
Name symptoms of intravascular local anesthetic injection
And with epinephrine?
Tinnitus
Blurry vision
Peri-oral / fascial numbness
With epinephrine:
Palpitations
Tachycardia
Anxiety
What his the angle for hip flexion recommended in gyne surgery?
60 - 170 degrees
If a patient has menorrhagia and no local causes were found, vWD investigations are negative, what should you do?
Refer to hematologis to r/o:
Mild factor X1 deficiency
Platelet dysfunction
RARE: alpha 2-antiplasmin, Factor XIII deficiency
What is the risk of endometrial cancer with Cowden syndrome
13 - 19 %
What is the prevalence of menorrhagia in the general population?
And in patient with bleeding disorders
General population: 10 %
Bleeding disorders: 60 - 90 % (57 - 93 %)
What is the inheritance pattern of vWD
Types 1 and most of type 2: Autosomal dominant
Tye 3 and some type 2: Autosomal recessive
What is the appropriate discharge teaching for endometrial ablation?
Resume normal activities progressively
No intercourse x 1 week
Pain will resolve within 24h (NSAIDs + opioates)
Light vaginal bleeding x several weeks
Need for permanent contraception
RTC if fever, intense pain or profuse vaginal bleeding
What is the risk of endometrial cancer with Lynch syndrome
22 - 50 %
What is the rate of progression to endometrial cancer in patients with endometrial hyperplasia with atypia treated with progestins
25 % (average time to cancer: 4 years)
Through what mechanism of action do COCs improve menorrhagia in vWD patients?
Increasing plasma levels of factor VIII and vWF
At what size should an endometrioma be excised?
> 3 cm
Excision improves pain, recurrence etc but decreases pregnancy rates
Consider drainage/ablation/ surgical management if < 3cm
What is the recommended level of vWF for procedures/ delivery
0.5 U/mL
Keep at that level
- 3-4 days post SVD
- 4-5 days post CS
Describe the initial laboratory investigations for menorrhagia (4+3)
Platelet count
Hemoglobin
Prothrombin (PT)
activated partial thromboplastin time (aPTT)
Consider:
TSH
PLR
Liver profile
What is the success rate en endometrial ablation?
73-85 % (regardless of technique)
In what circumstances would you request von Willebrand studies?
Menorrhagia present since menarche
Evidence of anemia or iron deficiency
Personal or family history of bleeding after hemostatic challenge (dental procedures, surgery, pregnancy)
No local cause of menorrhagia
What is the most common inherited bleeding disorder?
What are other bleeding disorders
Most common: von Willebrand disease
Other: Factor XI deficiency, mild platelet disorders
How do you follow an endometrioma?
Repeat imaging at 6 -12 wks to r/o hemorrhagic cyst (vs endo)
TVUS yearly
At what age can you start GnRH agonist with add back for adolescents?
18 yo – for everyone (after other tx failed)
16 yo – if laparoscopically proven endometriosis and not other effective tx
Define secondary dysmenorrhea (#345)
Menstrual pain associated with underlying pelvic pathology (ex endometriosis)
How can you prevent fluid overload in hysteroscopy (3)
Pre-treat the endometrium
Intracervical injection of pressors (vasopressin/ epinephrine)
Distension pressure < patient’s MAP
Indication to repeat Abx prophylaxis (2)?
When should pre-op prophylaxis given?
Sx > 4h EBL > 1.5 L
15 - 60 min before incision
What is the recommended degree of knee flexion in gyne surgery?
90 - 120 degrees
What needs to be present for the histological diagnosis of endometriosis?
(# 164)
Endometrial gland and stroma
What is the main mechanism of action of DMPA for chronic pelvic pain?
(#345)
1 = Suppression of ovulation
Does surgical treatment of endometriosis lesion decrease dysmenorrhea ?
(#345)
Yes !
Ablation or excision
Name effective mechanisms (techniques) effective to decrease primary dysmenorrhea (5)?
(#345)
Supression of ovulation
Amenorrhea (by any mean)
Hysterectomy
Laparoscopic nerve ablation (in some cases)
Endometrial ablation (with menorrhagia)
Is a pelvic examination / or US required to initiate primary dysmenorrhea treatment?
(#345)
Pelvic exam : no
Indication: not responding to therapy or organic disease suspected
What alternative methods can be used for management of primary dysmenorrhea (
(#345)
Regular exercise
Local heat pads
High frequency transcutaneous electrical nerve stimulation
Acupoint stimulation
Ginger
Which complications are decreased with laparoscopy vs laparotomies ?
(#193)
Minor complications ↓ by 40 %
Major complications rates are similar
Describe Palmer’s point
(#193)
Midclavicular line
3 cm below the left subcostal border
How is the umbilicaus of obese women displaced?
(#193)
Caudally to the aortic bifurcation by 2.9 cm
What is the advantage of tucking arms in gyne surgery (3)?
(#386)
↓ brachial plexus injury
↓ ulnar nerve injury
Surgeon’s comfort
What landmark can be used for “umbilical” abdominal entry in obse patients?
(#386)
1/2 way between pubic symphysis and xyphoid in the midline
Can also use palmer’s point
- Mid clavicular
- 2-3 cm from costal margin
What are the advantages of using Palmer’s point for entry in obese patients (5)?
(#386)
Less fat compared to umbilicus
Less adhesions compared to umbilicus
Distance to underlying organs increased (in obese patients)
Prevent entry at umbilicus that migrated caudally (3-6 cm from aortic bifurcation in obese)
Use of bony structure as landmark may be more reliable
Describe techniques to improve visualization in obese patient laparoscopy without increasing pressure (5)
(# 386)
Foley lap lift
Release peritoneal adhesion of sigmoid
Suspend bowel with epiploic appendices
Suspension of ovaries anteriorly/ laterally
Suspension of bladder via stitch through para-vesical fat
Why is OSA a concern for gyne surgery/ anesthesia ?
(#386)
↑ respiratory complications
↑ cardiac events
In which population is bariatric surgery recommended ?
(#386)
Class III
Class II with comorbidities
Which type of fibroid is more responsive to hormones ?
(#321)
Submucosal fibroids (vs subserosal)
How many days pre-op should you stop the following medication:
Warfarin
Dabigatran (Pradaxa)
Rivaraxaban (Xarelto)
Apixaban (Eliquis)
(UpToDate)
Warfarin : 5 - 6 days
Measure PT/ INR day before
- INR < 1.4 → ok for surgery
- INR > 1.5 → give oral vitamin K (1-2g PO) and recheck next day
All others: 2-3 days
What are key principles for ventilating ARDS patients?
Low tidal volume
Low inspiratory pressures
High PEEP
What are the diagnostic criteria of ARDS?
Acute onset
Bilateral infiltrates on CXR
Pulmonary artery wedge pressure < 18 mmHg
Severe hypoxemia PaO2/FiO2 < 200 mmHg
What are the diagnostic criteria for PMS (4)?
What is the cut-off size for single procedure removal of a sumucosal fibroid by hysteroscopy?
(#321)
Fibroid < 5 cm
For larger fibroids, repeat procedures are often required
For abdominal myomectomies, what kind of uterine incision should be used in priority?
(#321)
Anterior incision to minimize adhesions
Posterior incision: 94% adhesion
Anterior incision: 55 %
What are the timing criteria associated with PMS ?
(UpToDate)
What are associated symptoms?
Onset within 5 days of onset of menses (no end point)
Repetitive for at least 3 consecutive cycles
1-4 symptoms that are either physical, behavioral, affective/psychological
≥ 5 physical or behavioral symptoms
Affective symptoms :
- Irritability = most common
- Depression, anxiety, sensitivity to rejection, food craving, ↓ interest in activities
Physical symotoms:
- Bloating + extreme fatigue = most common
- Breast pain, swelling, HA, diziness
- Hot flashes (highly suggestive of PMS or PMDD if not peri menopause)
What are treatment options for PMS/ PMDD (4)?
Exercice/ relaxation (PMS)
Vitex Agnus Castus (Chasteberry) 20 - 40 mg daily (PMS)
If contraception needed: GnRH agonists / OCP
If no contraception: SSRI (continous, cyclical - D14 or onset of symptoms)
What is the difference between PMS and PMDD ?
Severe form of PMS where symptoms of anger, irritability and internal tension are prominent
Long list of DSM5 symptoms
Symptoms x 1 year
What organic issue is important to R/O before giving a dx of PMS?
Hypo/ Hyper T4
Name the absolute contra-indications to MA with MTX/MISO (8)
(#332)
Confirmed or suspected ectopic pregnancy
Anemia with Hb < 95
IUD
IBD
Active liver of renal disease
Hemorrhagic disorders or using concurrent anti-coag therapy
Known hypersensitivity MTX, MISO
Ambivalent
Name the absolute contra-indications to MIFE/MISO (7)
(#332)
Ectopic pregnancy
Chronic adrenal failure
Potent anti-glucocorticoid
Uncontrolled asthma
Inherited porphyria
Known hypersensitivity to the ingredients
Ambivalence
Until what GA can MIFE/MISO be used?
What about MTX/MISO
(#332)
MIFE/MISO : 49 days (70)
MTX/MISO: 63 days
Name the relative CI to MIFE/MISO MA (5)
(#332)
Unconfirmed GA
IUD
Concurrent long-term systemic corticosteroids
Hemorrhagic disorder
Concurrent anti-coagulation
What is the mean number of day to completion of abortion for MTX/MISO and MIFE/MISO (375)?
MIFE/ MISO: 3.3 days
MTX/ MISO: 7.1 days
When does fetal RBC start expressing Rh antigen
52 days from LMP
What should you do before scheduling a MA (6+1)?
(#332)
CBC
Beta hCG
Ultrasound
Blood group
STI screening or prophylaxis (gono/chlam)
Removing of IUD prn
Liver enzymes/ Renal function if MTX
What is the rate of D+C after medical abortion with MIFE
(#322)
3-5 %
How long after MA does fertility returns?
(#332)
20 days +/- 5 days
(ovulation as early as 8 days)
What size canula should be used for surgical abortions?
(#360)
# of complete weeks or 1 mm smaller
(9+6 weeks = 9 weeks)
How should beta evolve to confirm a successfull MA ?
(#332)
Fall in beta of 80 % from pre-treatment to 7-14 d post Rx
Does anticoagulation need to be stopped prior to surgical T2 abortion?
(#360)
no until GA = 84 days (12 weeks)
What are the 3 conditions for lactational amenorrhea method ?
What is the rate of efficacy?
(contraception part 4)
< 6 months post partum
Fully or nearly fully breastfeeding
Remained amenorrheic
If these 3 conditions are fulfilled → 98 %
What is the most common method of contraception in Canada?
(contraception part 5)
Male condoms
What is the % reduction of HIV transmission with male condoms?
(part 5)
80 %
List contraindications to permanent sterilization (7)
(part 6)
Systemic health problem –> risk of anesthesia
Pregnancy (unless immediate PP or post abortion)
Current or recent PID (within 3 months)
Cervical, ovarian, endo ca
GTN
Known allergy to contrast media (for Essure)
Uncertain about permanency
Uterine malformation and RPL. Rank in order of importance
(Berghella OB)
Septate (SAB rate = 65%) > didelphis > Bicornuate
Arcuate = not associated with RPL
Wickham striae are associated with which disease?
Lichen planus
Involves vagina
Also linked to ulcers of mucus membranes, flexor surfaces
Tx: steroids, tacrolimus
Systemic: steroids, azathioprine, cyclosporine, hydroxychloroquine
