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Royal College > Gynecology Guidelines > Flashcards

Gynecology Guidelines Flashcards

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1
Q

Tests for vonWillebrand disease

A

Factor VIII
vWF antigen
vWF functional assay

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2
Q

Most common inherited bleeding disorders?

How are they inherited and what tests would be abnormal?

A

Hemophilia A - X-linked recessive - low factor VIII - prolonged PTT
Hemophilia B - X-linked recessive - low factor IX - prolonged PTT
vWB - autosomal dominant - low factor VIII, vWF antigen and assay - prolonged PTT and bleeding time

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3
Q

First line treatment for menorrhagia in women with inherited bleeding disorders?
Other hormonal options?
Non-hormonal options?

A

OCP (50% decrease)
causes increase in plasma levels of factor VIII and vWF
Can consider Depo (if bleeding not severe), Mirena, Danazol, GnRH agonist
Non-hormonal: TXA, desmopressin, NSAIDs (*only COX2 inhibitors), blood, ablation or hysterectomy

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4
Q

Define Allodynia

A

Pain from stimuli that are not normally painful

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5
Q

Incidence of endo in women having lap for CPP

A

30%

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6
Q

Best imaging test to assess adenomyosis?

A

MRI (sens + spec 86-100%)

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7
Q

Medication to treat interstitial cystitis?

A

Pentosan polysulfate

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8
Q

Risk factors for endometriosis?

A 
Family history (3-10x)
anomalous reproductive tracts
nulliparity
subfertility
prolonged intervals since pregnancy
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9
Q

Classes of medications used to treat endometriosis

A 
CHC
Progestins (PO, IM, IUD)
Danazol
GnRH agonist
?Aromatase inhibitors
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10
Q

Indications for surgical management of endometriosis

A
  1. not responding to medical tx
  2. acute adnexal event
  3. severe invasive disease
  4. endometrioma >3cm and pelvic pain
  5. endometrioma and infertility
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11
Q

GnRH agonists are contraindicated in girls <18yo (T/F)

A

False. Can use if 16-18yo and endo confirmed by laparoscopy and persistent pelvic pain after trial of NSAIDs, OCP etc.

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12
Q 
VTE risks:
baseline @ reproductive age?
on OCP?
pregnancy?
immediate PP?
A

Baseline: 4-5/10,000
on OCP: 9-10/10,000
Pregnancy: 30/10,000
Imm PP: 300-400/10,000!

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13
Q

Non-contraceptive benefits of OCP?

A

Regulates cycles
Improves dysmenorrhea
improves PMS, hirsutism, acne
Decreased risk of ovarian, endometrial, colorectal ca

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14
Q

Define: Hypoactive sexual desire

A

Persistent/recurrent deficiency of sexual fantasies/desire for sexual activity

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15
Q

Define: sexual aversion disorder

A

Persistent/recurrent extreme aversion/avoidance of genital sexual contact with a sexual partner

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16
Q

Define: sexual arousal disorder

A

Persistent/recurrent inability to attain/maintain adequate lubrication/excitement

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17
Q

Define: orgasmic disorder

A

inability to achieve orgasm with adequate excitement

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18
Q

Define: dysparunea

A

Persistent/recurrent genital pain associated with sexual intercourse

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19
Q

Define: Vaginismus

A

Persistent/recurrent involuntary contraction of the perineal muscles surrounding outer 1/3 of vagina with penetration

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20
Q

Which of the following have been shown NOT to negatively impact sexual function?

a) Alcohol
b) Cannabis
c) Opioids
d) Cocaine

A

b) Cannabis (improves sexual function)

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21
Q

Stages of vaginismus

A

Stage 1: perineal spasm, not maintain t/o exam
Stage 2: perineal spasm, maintained t/o exam
Stage 3: levator spasm and elevation of buttocks
Stage 4: perineal and levator spasm, elevation, adduction and retreat

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22
Q

Absolute C/I to IUD insertion

A 
Current PID
Purulent cervicitis
Current G/C
Undiagnosed vaginal bleeding
unresolved GTN
Patient refusal
Allergy
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23
Q

Two reasons to remove IUD in women who develop mild/mod PID

A

Patient request

Failure of symptoms to improve after 72h of treatment with appropriate antibiotics

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24
Q

Lifetime risk of endometrial ca in woman with Lynch?

Ovarian ca?

A

40-60% endo

10-12% ovarian

25
Q

Which would NOT be a good first-line medication for treatment of HMB?

a) Micronor (POP)
b) depoprovera
c) Mirena IUD
d) Mefenemic acid

A

a) micronor

Good for contraception, not studied for treatment of menorrhagia

26
Q

Risks of endometrial ablation

A 
Bleeding
Infection
Perforation
Injury to bowel/bladder/cervix/vessels
Fluid overload
Hematometria (post-ablation syndrome)
27
Q

Differential diagnosis (causes) of AUB?

A 
PALM-COIEN
P - polyps
A - adenosine
L - leiomyoma
M - malignancy/hyperplasia
C - coagulopathy
O - ovulatory dysfuntion
I - iatrogenic 
E - endometrial
N - NYD
28
Q

Risk factors for development of fibroids

A 
Nulliparity
Early menarche
Family hx
Obesity
African descent 
Age (peak 40-50)
Diabetes
HTN
29
Q

Most common symptom of fibroids:

a) pelvic pain
b) AUB
c) infertility

A

AUB (30%)

Pain is rare, due to degeneration/torsion

30
Q

Majority of fibroid growth is during the proliferative phase of the menstrual cycle? (T/F)

A

False. Secretory

31
Q

Required investigations prior to EA

A

Pregnancy test
Endometrial biopsy
Pap w/in 2 years (+/- swabs)
Cavity assessment

32
Q

3 methods to reduce fluid absorption during EA

A 
Pretreat endometrium
Distension pressure < MAP
Intracervical pressors (vasopressin, epinephrine)
33
Q

Advantages of NR EA vs. Resectoscopic

A

Shorter surgical time
Can be done under local anesthetic (not in OR)
Fewer uterine perforations
Lower risk of fluid overload
Less hematometria
Fewer cervical lacerations
BUT increased cramping, post-procedure N/V

34
Q

Techniques to reduce risk of capacitative coupling injury during R EA

A 
Use "cut" more than "coag" (lower voltage)
Avoid over-dilating cervix
Ensure loop is touching tissue
Weighted spec in vagina
Ensure insulation intact over device
Avoid prolonged/uninterrupted activation
35
Q

At a glycerine deficit of 500cc, the surgeon and anesthetist should be made aware.
How would your management change at a deficit of 1000cc? 1500cc?
What if you were using NS (bipolar)?

A

1000cc - finish procedure ASAP
Consider placing foley to monitor ins/outs, IV TKVO and IV furosemide
1500cc - stop immediately
Lytes in PACU, observe for signs of fluid overload + encephalopathy (change in LOC, seizure, pulm edema, tachypnea), consider admission
if using NS, finish procedure asap at 2000cc and immediately at 2500

36
Q

Contraindications to NR EA

A

Previous classical or transmural myomectomy

37
Q

What is the dose for the mife/miso medical abortion regimen?

A

Mifepristone 200mg PO, then 24-48h later, miso 800mcg buccal/SL/vaginal (can be used up to 70d)

38
Q

Absolute C/I to medical abortion with mife/miso?

Relative?

A 
Chronic adrenal failure
Ectopic pregnancy
Ambivalence
Inherited porphyria
Uncontrolled asthma
Allergy/hypersensitivity
Relative:
Unknown GA
IUD in place
Long-term systemic glucocorticoids
Hemorrhagic d/o or anticoagulation therapy
39
Q

Dose for the MTX/miso medical abortion regimen?

A

MTX 50mg PO/IM, 3-5d later Misoprostal 800mcg PV (can be used up to 63d)

40
Q

Contraindications to MTX MA therapy

A 
Ectopic
Anemia
IUD
IBD
Acute liver/renal disease
Hemorrhagic d/o or anticoagulation therapy
Allergy
41
Q

Criteria on U/S to confirm pregnancy failure

A
  1. CRL >7mm with no FHR
  2. MSD >25mm with no embryo
  3. No embryo >2weeks after u/s with GS but no YS
  4. No embryo >11d after u/s with GS and YS
42
Q

Ca requirements are higher in adolescents than in post-menopausal women?

A

True
9-18yo: 1300mg/d
19-50: 1000mg/d
>50: 1200mg/d

43
Q

Which is NOT a risk factor for PONV?

a) female sex
b) hx of PONV, motion sickness
c) smoker
d) use of post-op opioids

A

c) smoker

NON-smokers are at higher risk of PONV

44
Q

Describe the minimum acceptable preoperative evaluation for a women wishing surgery for SUI (6 points)

A
  1. focused hx
  2. pelvic exam (r/o masses, assess prolapse, r/o latent sui)
  3. demonstrate UVJ hypermobility (q-tip test, observation)
  4. objective evidence of SUI (including assessment for latent) - cough test while supine or stress test (fill bladder and cough while standing over towel)
  5. PVR (<100cc N)
  6. Urine R&M, C&S
45
Q

List four indications for Urodynamic testing

A
  1. Diagnosis uncertain after initial H&P
  2. Objective findings do not correlate with patients symptoms
  3. Patient fails to improve after treatment
  4. Clinical trial setting
46
Q

Which regimen would not be appropriate for treatment if an uncomplicated UTI?

a) Septra DS i tab PO BID x 3d
b) Macrobid 100mg PO BID x 3d
c) Ciprofloxacin 250mg PO BID x 3d
4) Fosfomycin 1 dose PO x 1

A

b) microbid should be given for at least 7 days

47
Q

Elements of Chronic Pain Syndrome? (4)

A
  1. duration 6mo or longer
  2. incomplete relief with most treatments
  3. impaired function at home or work, altered family roles
  4. signs of depression
48
Q

38yo G2P2 with 4cm ovarian endometrioma seen on U/S. Management?

A

Excise if symptoms or wishing fertility, otherwise expectant management

49
Q

Most common cause of secondary dysmenorrhea in adolescents?

A

Endometriosis

50
Q

Classic triad of endometriosis clinical symptoms

A

dysmenorrhea, dyschezia, dysparunia

51
Q

Which women MUST have an endometrial biopsy?

A
  1. PMB
  2. > 35 with AUB, anovulation
  3. Pyometria
  4. > 45yo with endometrial cells on pap
  5. Bleeding on Tamoxifen
  6. Yearly HNPCC
  7. Perimenopausal with AUB
52
Q

In women with dysparunea and chronic vulvar pain, it is reasonable to start a 3-6mo course of anti fungal/anti viral if no cause of her symptoms can be found (T/F)

A

True….

53
Q

What is the mechanism of action of TXA?

A

anti-fibrinolytic, reversibly binds to plasminogen and prevents its activation

54
Q

What effect does TXA have on coagulation factors?

A

None

55
Q

Options for reducing blood loss at the time of myomectomy?

A 
Vasopressin
Epinephrine
Bupivicaine
Misoprostal
Pericervical tourniquet
gelatin-thrombin matrix
TXA
UA occlusion
56
Q

Most fibroids grow during pregnancy (T/F)

A

False, usually don’t change in size or get smaller

57
Q

Describe Post-Embolization Syndrome

A

Fever, nausea, vomiting, pain

58
Q

In which patients would lactational amenorrhea be a reasonable option for contraception?

A
  1. <6mo PP AND
  2. EBF AND
  3. not resumed menses (amenorrheic)
59
Q

How long do you need to use backup contraception after a lap tubal? Essure? Vasectomy?

A

1 week
3 months
2-3 months (1 fresh sample must show azoospermia or <100,000)

Royal College (8 decks)

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