O&G Flashcards
PPH - define, types, causes, RFs & management
Definition: Bleeding after delivery of the baby & placenta, loss of 500mL after vaginal delivery or loss of 1000mL after caesarean section
• Minor: <1000mL blood loss • Major: >1000mL blood loss ○ Moderate: 1000-2000mL ○ Severe: >2000mL * Primary: bleeding within 24hrs of birth * Secondary: 24hrs-12 weeks after birth
Aetiology & Risk factors: 4 broad causes of PPH - ''4Ts'' • Tone - uterine atony (most common) • Trauma - laceration or tear • Tissue - retained placenta • Thrombin - coagulopathy
Risk factors for PPH include: • Previous PPH • Multiple pregnancy • Obesity • Large babies • Failure to progress in 2nd stage of labour • Prolonged 3rd stage
* Pre-eclampsia * Placenta accreta * Retained placenta * Instrumental delivery * General anaesthesia * Episiotomy or perineal tear
Preventative Measures
Several measures can reduce risk of PPH
• Treating anaemia in antenatal period
• Giving birth w/ empty bladder - a full bladder reduces uterine contractions
• Active management of 3rd stage of labour - IM oxytocin
• IV tranexamic acid during C-section in 3rd stage for higher risk patients
Management:
Senior MDT help approach involves:
• ABCDE approach & resuscitation
• Lie mum flat, keep her warm & good communication
• Insert 2 large bore cannulas
• Bloods - FBC, U&Es, clotting screen
• G&S and X match 4 units
• Warmed IV fluid & blood resuscitation as required
• Oxygen - regardless of sats
• Fresh frozen plasma when clotting abnormalities or after 4units
• In severe cases the major haemorrhage protocol can be activated
Treatment Options
Mechanical
• Bimanual compression - stimulate uterine contraction
• Catherization
Medical
• Oxytocin - slow injection f/b continuous infusion
• Ergometrine (IV or IM) - smooth muscle contraction
○ C/I in HTN
• Carboprost (IM) - is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
• Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
• Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
Surgical
• Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
• B-Lynch suture – putting a suture around the uterus to compress it
• Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
• Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
Secondary PPH - define, causes & management
Secondary postpartum haemorrhage Bleeding occurs from 24 hours to 12 weeks postpartum
This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).
Investigations involve:
• Ultrasound for retained products of conception
• Endocervical and high vaginal swabs for infection
Management depends on the cause:
• Surgical evaluation of retained products of conception
• Antibiotics for infection
Ovarian Cancer - types, RFs, S&S, ix & management
Definition: Malignancy of ovaries - epithelial cell tumours (various subtypes), germ cell tumours
Aetiology & Risk factors: • Age - peak age 60 • Increased number of ovulations ○ Nulliparity ○ Early menarche/late menopause • Family hx & BRCA • Obesity • Smoking
Presentation/Clinical Features: Late presentation w/ non-specific symptoms • Bloating • Early satiety • Loss of appetite • Bowel sx
* Weight loss * Abdominal or pelvic mass * Ascites * Lymphadenopathy
Investigations & Diagnosis: • Abdominal examination • Bloods - FBC, Ca125, Ca19-9 ○ AFP & HCG in women <40yrs • 2WW referral - ''examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids).'' • USS - abdomen + transvaginal USS • Calculate RMI (risk of malignancy index) = USS x Ca125 x menopause status • PET-CT/MRI for staging abdomen pelvis
Management:
MDT strategy, discussion & planning
• Surgery - hysterectomy + bilateral salphingo-oophorectomy +/- lymph node/related dissection/removal
• Staging (FIGO) via histology after surgery
• Chemotherapy
Cervical Cancer - types, RFs, S&S, ix & management
Definition: Malignancy of cervix - squamous cell carcinoma (85%), adenocarcinoma or rarer forms e.g. malignant melanoma, sarcoma
Aetiology & Risk factors: • BRCA1/BRCA2 family history • HPV infection • Unattendance for smears • HPV exposure - increased no. of sexual partners
* Smoking * COCP >5yrs * Increased no of full-term pregnancies * No vaccination
Presentation/Clinical Features: • Asymptomatic - picked up on screening • Post-coital bleeding • Inter-menstrual bleeding • Post-menopausal bleeding
* Pelvic Pain * Dyspareunia * Vaginal discharge
Differentials (for PCB) - ectropion, vaginal dryness, vaginal fissure
Investigations & Diagnosis:
• Speculum examination
○ ‘abnormal/suspicious’ looking cervix –> 2WW
• 2WW referral if seen in GP
○ ‘‘on examination, the appearance of their cervix is consistent with cervical cancer.’’
• Bloods - FBC, U&Es, LFTs
• Colposcopy - visualisation of cervix, acetic acid & iodine dye tests, biopsies
• MRI pelvis, CT abdomen and chest
• Clinical staging = FIGO
Management:
• LLETZ (large loop excision of transformation zone) or cone biopsy for CIN or early stage disease
○ Implication/important to know if obstetric hx
• Surgery - hysterectomy + bilateral salphino-oophorectomy +/- lymph node dissection
• Chemo/radiotherapy
• Palliative care options
Endometrial Cancer - types, RFs, S&S, ix & management
Definition: Malignancy of endometrium - adenocarcinoma
Aetiology & Risk factors:
Oestrogen risk - more exposure to oestrogen/unopposed oestrogen increases risk of endometrial hyperplasia & cancer
• Obesity, diabetes mellitus, hypertension
• Unopposed oestrogen (HRT)
• Diabetes and hypertension
• Family history of breast cancer, colorectal cancer (hereditary non-polyposis colorectal cancer) and endometrial cancer
• Nulliparity - no or fewer pregnancies
• Early menarche +/- late menopause
Presentation/Clinical Features:
• Most cases of endometrial cancer present with post-menopausal bleeding
○ i.e. no periods for 12mths followed by episodes of bleeding
• Abnormal vaginal discharge
• Can also present with IMB, PCB, anaemia or high plts
Differentials for PMB - endometrial or vaginal atrophy, HRT bleed, ‘physiological bleed’, vaginitis, endometrial/cervical polyp
Investigations & Diagnosis: • Examination - consider speculum +/- bimanual examination • Abdominal & Transvaginal USS ○ Endometrial thickness should be <4mm post menopausally • Endometrial pipelle biopsy • Hysteroscopy + dilatation + curettage • MRI/CT abdomen & pelvis for staging • Chest X ray • Bloods-FBC,U&E and LFT
Management:
MDT discussion & plan
• Surgery (Hysterectomy and removal of ovaries)
• FIGO Staging after surgery determined by histology results
• Chemotherapy/Radiotherapy
• Hormonal therapy (progesterone) - palliative
What is CIN?
Cervical intraepithelial neoplasia
Grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening).
• CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
• CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
• CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
What is the current cervical smear regime in UK?
First call at age 24.5 years.
Screening is not recommended to < 25-year-olds.
Human Papilloma Virus testing (HPV) can be identified on the samples rather than doing a cytology assessment, increases sensitivity.
If HPV screen is negative, follow-up is three-yearly up to the age of 49, and then five-yearly up to the age of 65.
If HPV is positive cytology will be assessed and referral to colposcopy indicated if there is dyskaryosis.
Vulval Cancer - define, RF, S&S, ix & management
Definition: Rare compared with other gynaecological cancers. Around 90% are squamous cell carcinomas. Less commonly, they can be malignant melanomas.
Risk Factors
• Advanced age (particularly over 75 years)
• Immunosuppression
• Human papillomavirus (HPV) infection
• Lichen sclerosus
○ Around 5% of women with lichen sclerosus get vulval cancer.
Presentation/Clinical Features • Vulval lump • Ulceration • Bleeding • Pain • Itching • Lymphadenopathy in the groin
Investigations & Management
Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral.
Establishing the diagnosis and staging involves:
• Biopsy of the lesion
• Sentinel node biopsy to demonstrate lymph node spread
• Further imaging for staging (e.g. CT abdomen and pelvis)
The International Federation of Gynaecology and Obstetrics (FIGO) system is used to stage vulval cancer.
Management depends on the stage, and may involve:
• Wide local excision to remove the cancer
• Groin lymph node dissection
• Chemotherapy
• Radiotherapy
Describe Antenatal Screening Tests
Combined test (10-13+6 weeks): USS (NT) + PAPPA + bHCG
Triple/Quad test (14-20 weeks, all bloods): bHCG, AFP, serum oestriol +/- inhibin A
When the risk of Down’s is greater than 1 in 150 (occurs in around 5% of tested women), the woman is offered amniocentesis or chorionic villus sampling perform karyotyping
CVS involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks).
Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.
Fibroids - RFs, S&S, inx & management
Definition: Benign tumours of myometrium of uterus, usually arising in women of child bearing age. They may be asymptomatic or present with variety of symptoms
Aetiology & Risk factors:
Fibroids are hormone-driven - high levels of oestrogen & progesterone
• Age - child bearing
• Early age of puberty
• Ethnicity - increased prevalence in black females
• Obesity
Pregnancy reduces the risk of fibroids, progestogen-only contraceptives also appear to reduce the risk.
Pathogenesis:
Hormone driven benign myometrial tumours. Depending on the location of fibroids, they may be classified as subserosal, intramural or submucosal.
Presentation/Clinical Features: Can be asymptomatic & be incidentally picked up on imaging or present w/ the symptoms below • Menorrhagia • Abdominal swelling • Pelvic pain • Dyspareunia • Dysmenorrhoea • Urinary/bowel symptoms
Fibroids can also undergo ‘red degeneration’ during pregnancy
• result of rapid enlargement causing the fibroid to outgrow its blood supply. This can lead to acute severe abdominal pain
Investigations & Diagnosis:
• Bloods - especially in work up of menorrhagia
○ Hb to check for anaemia
• Pelvic USS - gold std
○ Trans-vaginal & abdo
• Pelvic MRI +/- hysteroscopy: if concern about intramucosal fibroids or malignancy
Management:
Conservative
• Reassurance - especially if asymptomatic
• Heavy periods - advice & iron supplements if anaemic
Medical
• Intra-uterine contraceptive system (IUS)
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Tranexamic acid and/or
• Combined oral contraceptive pill
Surgical
• Myomectomy or hysterectomy
Endometriosis - define, RFs, S&S, inx, management
Definition: Implantation & growth of endometrial tissue outside of uterine cavity
Aetiology & Risk factors: Exact aetiology is still unclear & unknown • Early menarche • Late menopause • Nulliparity • Delayed childbearing
- Short menstrual cycle
- Family history
- White ethnicity
Presentation/Clinical Features: • Menorrhagia • Dysmenorrhea • Dyspareunia • Chronic Pelvic Pain • Sub/infertility
Often cyclical sx inc:
• Bloating & nausea
• LUTS
• Dyschezia
Investigations & Diagnosis:
Bloods
• FBC - Hb to check for anaemia
Imaging
• USS - TVUSS is preferred but trans-abdominal can be used if more appropriate
○ Useful for excluding other potential pathologies
§ Masses, ovarian cysts, PID
• MRI - not typically the first line investigation
○ may be used in those with suspected deep endometriosis, particularly affecting the bowel, bladder or ureter
• Laparoscopy - gold std for diagnosis
○ Can take samples/biopsy for histology
Management:
Conservative
• Pain relief - good analgesia & education
○ NSAIDs/paracetamol
Medical
• Hormonal therapies - can significantly reduce the pain
○ Options include combined oral contraceptive pill, progesterone only pill, the implant and the Mirena coil
• GnRH analogues e.g. buserelin, gonadorelin - short term due to bone
Surgical management
· Excision or ablation
○ Laparoscopic ablation of endometrial tissue
· Hysterectomy may be performed in combination with surgical management, normally in patients with significant menorrhagia or adenomyosis that have not responded to more conservative measures.
○ & of course not wanting to conceive
Pelvic Organ Prolapse - define, types, RFs, S&S, management
Definition: Descent of pelvic organs into the vagina
• Uterine prolapse – uterus descends into vagina • Vault prolapse – occurs in women who have had a hysterectomy, top of vagina descends • Rectocele – defect in posterior vaginal wall, rectum prolapses forward into the vagina, a/w constipation, faecal loading & urinary retention, palpable lump • Cystocele – defect in anterior vaginal wall, bladder pushes backwards into vagina ○ Prolapse of the urethra is also possible - urethrocele) ○ Prolapse of both the bladder and the urethra is called a cystourethrocele.
Aetiology & Risk factors:
POP occurs due to a weakness & lengthening of muscles/ligaments surrounding uterus, rectum and bladder.
• Parity especially vaginal deliveries • Instrumental, prolonged or traumatic deliveries ○ Tears/episiotomy • Age & menopausal status • Obesity • Previous pelvic surgery • Chronic coughing/respiratory disease • Chronic constipation
Presentation/Clinical Features:
• Dragging sensation down into vagina
• Feeling or seeing a lump in the vagina
• Feeling of ‘vaginal fullness’
• Urinary symptoms - incontinence, frequency, urgency
• Lower back and pelvic pain
○ may become worse with prolonged standing or walking
• Bowel symptoms, such as constipation, incontinence and urgency
• Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
Grading system = pelvic organ prolapse quantification (POP-Q) score
• Grade 0: Normal
• Grade 1: descent within vagina
• Grade 2: descent to hymen
• Grade 3: descent beyond hymen
• Grade 4: Full descent with eversion of the vagina
Management:
Conservative management is appropriate for women that are able to cope with mild symptoms
• Physiotherapy (pelvic floor exercises)
• Weight loss
• Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
• Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
• Vaginal oestrogen cream
Vaginal pessaries
Surgical repair
Urinary Incontinence - define, types, risk factors & assessment
Definition: Involuntary flow/leakage of urine, types include stress incontinence, urge incontinence, mixed or overflow
Pathogenesis:
• Stress incontinence - increase in intrabdominal pressure
• Urge incontinence - overactivity of detrusor muscle, a/w OAB
Aetiology & Risk factors: • Age • Postmenopausal status • Increased BMI • Trauma • Multiparity & vaginal deliveries • Pelvic Organ Prolapse • Pelvic floor surgery • Neurological conditions e.g. multiple sclerosis • Cognitive impairment & dementia
Presentation/Clinical Features:
Stress Incontinence
• Incontinence on coughing/sneezing/laughing or when surprised
Urge Incontinence
• Having the sudden sensation of needing to pass urine, having to rush to the bathroom & not making it in time
Assessment, Investigations & Diagnosis: Begin with history; assessing & distinguishing between urge & stress incontinence • Identify modifiable risk factors ○ e.g. caffeine, alcohol, medications & BMI • Assess severity ○ Frequency of urination ○ Frequency of incontinence ○ Night time urination ○ Use of pads and changes of clothing
Examination; assess pelvic tone
• Pelvic organ prolapse
• Atrophic vaginitis
• Urethral diverticulum
• Pelvic masses
• Ask patient to cough & observe any incontinence
• In bimanual can assess tone by asking patient to squeeze
Investigations:
• Bladder diaries
• Urine dipstick & MSU; r/o infection, haematuria
• Bladder USS
Urodynamic testing; if no response to 1st line treatment
Management:
Stress incontinence
• Conservative; lifestyle changes (w/l, avoid caffeine, alcohol)
• Pelvic floor exercises; trial of 3mths supervised sessions, if improves sx patients should continue to do them
• Medical; duloxetine (SNRI)
• Surgery; tension free vaginal tape, sling procedures, colposuspension, intramural urethral bulking
Urge incontinence
• Conservative; bladder retraining exercises (at least 6 weeks)
• Medical; anti-cholingeric (oxybutynin), mirabegron
• Surgical; botox into bladder wall, p/c sacral nerve stimulation, augmentation cystoplasty
Urge incontinence - management
• Conservative; bladder retraining exercises (at least 6 weeks)
• Medical; anti-cholingeric (oxybutynin), mirabegron
Surgical; botox into bladder wall, p/c sacral nerve stimulation, augmentation cystoplasty
Stress Incontinence - management
Stress incontinence
• Conservative; lifestyle changes (w/l, avoid caffeine, alcohol)
• Pelvic floor exercises; trial of 3mths supervised sessions, if improves sx patients should continue to do them
• Medical; duloxetine (SNRI)
Surgery; tension free vaginal tape, sling procedures, colposuspension, intramural urethral bulking
