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RC OBGYN (CG) > Gyne > Flashcards

Gyne Flashcards

1
Q

What are the indications to admit a patient with a diagnosis of PID (7)?

A

Severe illness

Tubo-ovarian abscess

Cannot r/o other surgical emergency

Unable to take oral meds

Not responding to PO meds

Pregnancy

Non-reliable

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2
Q

What are the predictors of endometrial ablation failure (3)

A

Age < 40

Prior tubal ligation

Preoperative dysmenorrhea

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3
Q

What is the average age at diagosis of LMS

A

52

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4
Q

What is the change of concomittent endometrial cancer when hyperplasia with atypia is present

A

17 - 25 %

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5
Q

What causes endometrial implants to be so hyper-estrogenic?

A

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)
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6
Q

What is the most common adverse event following non- resectoscopic EA?

A

Pelvic pain

Cramping

Nausea/ vomiting

Resolve within 24h

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7
Q

What is the DDx of a black vulvar lesion?

A

Lentigo

Nevus

Vitiligo

Cherry Hemangioma

Melanosis

Sebrroric keratosis

Melanoma

VIN / Vulvar cancer

BCC

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8
Q

Should you give abx for cardiac patients to prevent endocarditis?

A

Not for GU procedures

If high risk pts and receiving abx for something else, should consider using Abx that will also cover enterococci

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9
Q

What is the % of patient requiring a hysterectomy within 10 years of a myomectomy

A

10 %

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10
Q

What is the risk of PPH in patient with vWD/ Facto XI/ hemophilia carriers

A

16 - 22 %

Normal population 4-5 %

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11
Q

What are potential test that may aid in LMS pre-op dx

A

MRI

Serum LDH

Endometrial biopsy

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12
Q

Name the side effects of progesterone (4)?

A

Acne

GI Upset

Edema

Weight gain

Irregular menstrual bleeding

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13
Q

What is the risk of occult sarcoma at time of fibroid surgery

A

1/350 - 1/2000

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14
Q

What ovary torts more frequently?

(#341)

A

Right ovary

(sigmoid?)

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15
Q

What is the incidence of vault prolapse post hysterectomy in patient with no evidence of POP

A

1-2 %

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16
Q

What is the most common cause of secondary dysmenorrhea?

Name other causes of secondary dysmenorrha (5)

A

The most common cause: Endometrioisis

Other causes:

Adenomyosis

Uterine myomas

Cervical stenosis

Obstructive lesions of the genital tract

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17
Q

Define primary dysmenorrhea (#345)

A

Menstrual pain in the absence of pelvic pathology

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18
Q

What is the inheritence pattern of vWD

A
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19
Q

About GnRH agonists for AUB,

1- What is the expected % schrinkage of fibroids

2- When is the greatest effect apparent

A

50 % decrease in initial volume

Greatest effect after 12 weeks

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20
Q

What progesterone and what dose is released daily with a Mirena ?

A

Levonorgestrel

20 ug/ day

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21
Q

What is the angle of knee abduction recommended in gyne surgery ?

A

< 90 degrees

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22
Q

What is the typical apparence of endometriotic lesions in adolescents?

A

Clear vesicles

Red lesions

vs: classic powder burn lesions

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23
Q

At what weight should you adjust pr-op abx?

A

120 kg

Previously BMI > 35

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24
Q

At what deficit should you abort a ablative procedure ?

For both types of media

A

Non conductive solutions : 1500 mL

(Glycine, mannitor, sorbitol, cystosol)

Conductive solutions: 2500 mL

(NS)

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25
Q

What is the mechanism of action of Desmopressin (DDAVP) for vWD

A

Releases vWF from storage sites within endothelial cells

–> increases vWF

–> increase plasma levels of factor 8

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26
Q

What are the alternative regiment for Abx prophylaxis in gyne surgery?

A

Clinda 600 mg IV

Erythro 500 mg IV

Flagyl 500 mg IV (?) - Dose not specified

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27
Q

What are the options to treat breakthrough bleeding (in patients w vWD)?

A

Double COC pill for 3-4 days

Add a 50 ug estrogen patch for 3-4 days

Change to a 50 ug pill

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28
Q

What are the anti-androgenic progestins

A

Norethedrone (NETA)

Drosperinone

Desogestrol

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29
Q

What are the types of vWD

A

Type 1 : partial quantitative reduction in VWF

Type 2: qualitative deficiency of VWF

Type 3: absence of VWF

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30
Q
A
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31
Q

What are the absolute contraindications to endometrial ablation (5)?

A

Pregnancy

Desire to preserve fertility

Endometrial cancer or hyperplasia

Cervical cancer

Pelvic infection

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32
Q

What is the most common cause of secondary dysmenorrhea in adolescents?

A

Endometriosis

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33
Q

What are the mechanism of fluid overload in hysteroscopy (3)?

A

Absorption across the endometrium

Intravasation through surgically opened venous channels

Spill from fallopian tubes with absorption by peritoneum

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34
Q

Name the RF for LMS (7)

(# 371)

A

Age > 50

Black race

Tamoxifen use

Previous pelvic radiation

Hereditary leiomyomatosis

Hx of hereditary retinoblastoma

Renal cell carcinoma

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35
Q

Are Abx recommended for HSG?

A

Only if tubes are dilated (doxy)

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36
Q

Are GnRH agonists linked to decreased bone mineral density

A

Yes (especially if used long term)

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37
Q

Is ablative or excisional treatment better for pain management in endometriosis?

A

No difference for pain (or fertility treatment)

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38
Q

List the 4 criteria for endometriosis and epithelial ovarian cancer

A

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

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39
Q

What is the treatment of choice for severe vWD?

How long does it last?

A

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)

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40
Q

Does hysterectomy alone affect ovarian reserve?

A

YES

2-fold increased risk of ovarian failure

> 20 % pts have symptoms of decreased ovarian reserve within 1y

Decrease AMH shown in studies

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41
Q

What are the risk factors for fluid overload (4)?

A

Use of hypotonic solutions (vs isotonic)

Long procedures

High distension pressure

Resection of large pieces of tissue

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42
Q

What are the options for treatment of acute hemorrhage post endometrial ablation (3)

A

AFTER r/o Uterine perforation:

Foley ballloon tamponade

Intracervical vasopressors injections

Misoprostol PR

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43
Q

What are potential complications of pregnancy following endometrial ablation (3)?

A

Uterine rupture

Limb defects

Premature labour

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44
Q

What is the rate of fibroid recurrence after myomectomy

A

15 %

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45
Q

Which treatment for endometriosis causes bone loss?

A

GnRH agonists

Depot-progestins

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46
Q

What is the preferred regimen of Abx for a therapeutic abortion?

A

Doxycycline

100 mg PO pre-procedure

200 mg PO post-procedure

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47
Q

What method of hysterectomy has the lowest post-op morbidity or complication rate

A

Vaginal

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48
Q

Name the investigations required before an endometrial ablation

A

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

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49
Q

What epithelial cancer is linked to endometriosis?

A

Clear cell cancer (35%)

Endometrioid (20%)

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50
Q

How do factor 8 (VIII) and vWF evolve in pregnancy ?

A

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

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51
Q

After how many weeks can we assess the efficacy of endometrial ablation

A

6 - 12 weeks post op

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52
Q

What is the first line therapy in patient with late PPH and vWD

A

Cyklokapron + OCP

Can start prophylactic OCP immediatly PP and for 1 month

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53
Q

What is the inheritence pattern of Hemophilia A and B

A

Both X linked

Hemophilia A (Factor 8 deficiency)

Hemophilia B (Factor 9 deficiency)

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54
Q

Are antibiotics recommended before endometrial ablation?

A

No

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55
Q

What are the criteria to observe vs operate an endometrioma?

A

Asymptomatic

Small endometrioma with classic findings

Established diagnosis of endometriosis

Stable Ca125

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56
Q

When should you supress ovarian function in women with endometriosis and infertility?

A

Patient who undergo IVF

(GnRH agonist x 3-6 mo)

Not effective for

  • mild to moderate disease
  • pre-op surgery for endometriosis
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57
Q

Which of the 2 medications have a shorter time to ammenorrhea - GnRHa vs Ulipristal

A

Ulipristal (7 vs 21 days)

58
Q

What is the ideal technique to remove superficial endometriosis for fertility purposes?

A

No difference in terms of fertility

Excision = ablation

Electrocautery = laser

59
Q

What should be added to GnRH agonist for treatment of endo in adolescents (3)?

A

Add back therapy

Calcium

Vitamin D

60
Q

What can decrease vWF levels (2)?

A

Hypothyroidism

Blood type 0 lower than type non-O

61
Q

Describe von Willebrand studies

A

Factor VIII

vWF antigen

vWF functional assay

62
Q

What are the most common adverse events in resectoscopic ablation (4)?

A

Uterine perforation

Fluid overload

Hematometra

Cervical lacerations

63
Q

What is the first line treament of menorrhagia in patient with bleeding disorders ?

A

COCs

64
Q

What is the inheritence pattern of vWD?

A

Autosomal dominant (Type 1 and some type 2)

Autosomal recessive (some type 2 and type 3)

65
Q

After how long off GnRH agonist treatment are fibroids expected to regrow?

What is the maximum length of continuous tx

A

12 weeks

3-6 months

66
Q

Name the contraindications to non-resectoscope EA (2)?

A

Classical CS

Transmural myomectomies

(Caution if > 2 CS)

67
Q

What are the indications for laparoscopy in endo patients with infertility?

A

1- Deep dyspareunia, severe dysmenorrhea, dyschezia

2- Tender nodules on uterosacrals

3- Persistent adnexal mass (remove endometrioma if diameter > 3 cm)

68
Q

What are the advantages of pre-treating the endometrium in resectoscopic EA (3)?

A

Higher short term amenorrhea

Decreased fluid absorption

Shorter operative times

(Better visualization)

69
Q

What are the 3 indications for surgical management of TOA?

A

Intra-abdominal TOA rupture

Failure to respond to ABX within 48-72h

Suspicion of other surgical emergencies (ex appy)

70
Q

What can increase vWF levels (8)?

A

Age

DM

Malignancy

Stress, exercice

Oral contraceptive

Pregnancy

Inflammation (acute or chronic)

Hyper thyroidism

71
Q

Name the effects of decreased estrogen exposure (5)

A

Hot flushes

Insomnia

reduced libido

vaginal dryness

headaches

72
Q

Name symptoms of intravascular local anesthetic injection

And with epinephrine?

A

Tinnitus

Blurry vision

Peri-oral / fascial numbness

With epinephrine:

Palpitations

Tachycardia

Anxiety

73
Q

What his the angle for hip flexion recommended in gyne surgery?

A

60 - 170 degrees

74
Q

If a patient has menorrhagia and no local causes were found, vWD investigations are negative, what should you do?

A

Refer to hematologis to r/o:

Mild factor X1 deficiency

Platelet dysfunction

RARE: alpha 2-antiplasmin, Factor XIII deficiency

75
Q

What is the risk of endometrial cancer with Cowden syndrome

A

13 - 19 %

76
Q

What is the prevalence of menorrhagia in the general population?

And in patient with bleeding disorders

A

General population: 10 %

Bleeding disorders: 60 - 90 % (57 - 93 %)

77
Q

What is the inheritance pattern of vWD

A

Types 1 and most of type 2: Autosomal dominant

Tye 3 and some type 2: Autosomal recessive

78
Q

What is the appropriate discharge teaching for endometrial ablation?

A

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

79
Q

What is the risk of endometrial cancer with Lynch syndrome

A

22 - 50 %

80
Q
A
81
Q

What is the rate of progression to endometrial cancer in patients with endometrial hyperplasia with atypia treated with progestins

A

25 % (average time to cancer: 4 years)

82
Q

Through what mechanism of action do COCs improve menorrhagia in vWD patients?

A

Increasing plasma levels of factor VIII and vWF

83
Q

At what size should an endometrioma be excised?

A

> 3 cm

Excision improves pain, recurrence etc but decreases pregnancy rates

Consider drainage/ablation/ surgical management if < 3cm

84
Q

What is the recommended level of vWF for procedures/ delivery

A

0.5 U/mL

Keep at that level

  • 3-4 days post SVD
  • 4-5 days post CS
85
Q

Describe the initial laboratory investigations for menorrhagia (4+3)

A

Platelet count

Hemoglobin

Prothrombin (PT)

activated partial thromboplastin time (aPTT)

Consider:

TSH

PLR

Liver profile

86
Q

What is the success rate en endometrial ablation?

A

73-85 % (regardless of technique)

87
Q

In what circumstances would you request von Willebrand studies?

A

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

88
Q

What is the most common inherited bleeding disorder?

What are other bleeding disorders

A

Most common: von Willebrand disease

Other: Factor XI deficiency, mild platelet disorders

89
Q

How do you follow an endometrioma?

A

Repeat imaging at 6 -12 wks to r/o hemorrhagic cyst (vs endo)

TVUS yearly

90
Q

At what age can you start GnRH agonist with add back for adolescents?

A

18 yo – for everyone (after other tx failed)

16 yo – if laparoscopically proven endometriosis and not other effective tx

91
Q

Define secondary dysmenorrhea (#345)

A

Menstrual pain associated with underlying pelvic pathology (ex endometriosis)

92
Q

How can you prevent fluid overload in hysteroscopy (3)

A

Pre-treat the endometrium

Intracervical injection of pressors (vasopressin/ epinephrine)

Distension pressure < patient’s MAP

93
Q

Indication to repeat Abx prophylaxis (2)?

When should pre-op prophylaxis given?

A

Sx > 4h EBL > 1.5 L

15 - 60 min before incision

94
Q

What is the recommended degree of knee flexion in gyne surgery?

A

90 - 120 degrees

95
Q

What needs to be present for the histological diagnosis of endometriosis?

(# 164)

A

Endometrial gland and stroma

96
Q

What is the main mechanism of action of DMPA for chronic pelvic pain?

(#345)

A

1 = Suppression of ovulation

97
Q
A
98
Q

Does surgical treatment of endometriosis lesion decrease dysmenorrhea ?

(#345)

A

Yes !

Ablation or excision

99
Q

Name effective mechanisms (techniques) effective to decrease primary dysmenorrhea (5)?

(#345)

A

Supression of ovulation

Amenorrhea (by any mean)

Hysterectomy

Laparoscopic nerve ablation (in some cases)

Endometrial ablation (with menorrhagia)

100
Q

Is a pelvic examination / or US required to initiate primary dysmenorrhea treatment?

(#345)

A

Pelvic exam : no

Indication: not responding to therapy or organic disease suspected

101
Q

What alternative methods can be used for management of primary dysmenorrhea (

(#345)

A

Regular exercise

Local heat pads

High frequency transcutaneous electrical nerve stimulation

Acupoint stimulation

Ginger

102
Q

Which complications are decreased with laparoscopy vs laparotomies ?

(#193)

A

Minor complications ↓ by 40 %

Major complications rates are similar

103
Q

Describe Palmer’s point

(#193)

A

Midclavicular line

3 cm below the left subcostal border

104
Q

How is the umbilicaus of obese women displaced?

(#193)

A

Caudally to the aortic bifurcation by 2.9 cm

105
Q

What is the advantage of tucking arms in gyne surgery (3)?

(#386)

A

↓ brachial plexus injury

↓ ulnar nerve injury

Surgeon’s comfort

106
Q

What landmark can be used for “umbilical” abdominal entry in obse patients?

(#386)

A

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
107
Q

What are the advantages of using Palmer’s point for entry in obese patients (5)?

(#386)

A

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

108
Q

Describe techniques to improve visualization in obese patient laparoscopy without increasing pressure (5)

(# 386)

A

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

109
Q

Why is OSA a concern for gyne surgery/ anesthesia ?

(#386)

A

↑ respiratory complications

↑ cardiac events

110
Q

In which population is bariatric surgery recommended ?

(#386)

A

Class III

Class II with comorbidities

111
Q

Which type of fibroid is more responsive to hormones ?

(#321)

A

Submucosal fibroids (vs subserosal)

112
Q

How many days pre-op should you stop the following medication:

Warfarin

Dabigatran (Pradaxa)

Rivaraxaban (Xarelto)

Apixaban (Eliquis)

(UpToDate)

A

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

113
Q

What are key principles for ventilating ARDS patients?

A

Low tidal volume

Low inspiratory pressures

High PEEP

114
Q

What are the diagnostic criteria of ARDS?

A

Acute onset

Bilateral infiltrates on CXR

Pulmonary artery wedge pressure < 18 mmHg

Severe hypoxemia PaO2/FiO2 < 200 mmHg

115
Q

What are the diagnostic criteria for PMS (4)?

A
116
Q
A
117
Q

What is the cut-off size for single procedure removal of a sumucosal fibroid by hysteroscopy?

(#321)

A

Fibroid < 5 cm

For larger fibroids, repeat procedures are often required

118
Q

For abdominal myomectomies, what kind of uterine incision should be used in priority?

(#321)

A

Anterior incision to minimize adhesions

Posterior incision: 94% adhesion

Anterior incision: 55 %

119
Q

What are the timing criteria associated with PMS ?

(UpToDate)

What are associated symptoms?

A

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)
120
Q

What are treatment options for PMS/ PMDD (4)?

A

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)

121
Q

What is the difference between PMS and PMDD ?

A

Severe form of PMS where symptoms of anger, irritability and internal tension are prominent

Long list of DSM5 symptoms

Symptoms x 1 year

122
Q

What organic issue is important to R/O before giving a dx of PMS?

A

Hypo/ Hyper T4

123
Q

Name the absolute contra-indications to MA with MTX/MISO (8)

(#332)

A

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

124
Q

Name the absolute contra-indications to MIFE/MISO (7)

(#332)

A

Ectopic pregnancy

Chronic adrenal failure

Potent anti-glucocorticoid

Uncontrolled asthma

Inherited porphyria

Known hypersensitivity to the ingredients

Ambivalence

125
Q

Until what GA can MIFE/MISO be used?

What about MTX/MISO

(#332)

A

MIFE/MISO : 49 days (70)

MTX/MISO: 63 days

126
Q

Name the relative CI to MIFE/MISO MA (5)

(#332)

A

Unconfirmed GA

IUD

Concurrent long-term systemic corticosteroids

Hemorrhagic disorder

Concurrent anti-coagulation

127
Q

What is the mean number of day to completion of abortion for MTX/MISO and MIFE/MISO (375)?

A

MIFE/ MISO: 3.3 days

MTX/ MISO: 7.1 days

128
Q

When does fetal RBC start expressing Rh antigen

A

52 days from LMP

129
Q

What should you do before scheduling a MA (6+1)?

(#332)

A

CBC

Beta hCG

Ultrasound

Blood group

STI screening or prophylaxis (gono/chlam)

Removing of IUD prn

Liver enzymes/ Renal function if MTX

130
Q

What is the rate of D+C after medical abortion with MIFE

(#322)

A

3-5 %

131
Q

How long after MA does fertility returns?

(#332)

A

20 days +/- 5 days

(ovulation as early as 8 days)

132
Q

What size canula should be used for surgical abortions?

(#360)

A

# of complete weeks or 1 mm smaller

(9+6 weeks = 9 weeks)

133
Q

How should beta evolve to confirm a successfull MA ?

(#332)

A

Fall in beta of 80 % from pre-treatment to 7-14 d post Rx

134
Q

Does anticoagulation need to be stopped prior to surgical T2 abortion?

(#360)

A

no until GA = 84 days (12 weeks)

135
Q

What are the 3 conditions for lactational amenorrhea method ?

What is the rate of efficacy?

(contraception part 4)

A

< 6 months post partum

Fully or nearly fully breastfeeding

Remained amenorrheic

If these 3 conditions are fulfilled → 98 %

136
Q

What is the most common method of contraception in Canada?

(contraception part 5)

A

Male condoms

137
Q

What is the % reduction of HIV transmission with male condoms?

(part 5)

A

80 %

138
Q

List contraindications to permanent sterilization (7)

(part 6)

A

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

139
Q
A
140
Q
A
141
Q

Uterine malformation and RPL. Rank in order of importance

(Berghella OB)

A

Septate (SAB rate = 65%) > didelphis > Bicornuate

Arcuate = not associated with RPL

142
Q

Wickham striae are associated with which disease?

A

Lichen planus

Involves vagina

Also linked to ulcers of mucus membranes, flexor surfaces

Tx: steroids, tacrolimus

Systemic: steroids, azathioprine, cyclosporine, hydroxychloroquine

RC OBGYN (CG) (13 decks)

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