O&G Cases 2,3, 10,12,16 Flashcards
What are the causes of bleeding in early pregnancy?
- Miscarriage
- Ectopic pregnancy
- Molar pregnancy
- Gynaecological issues
- Implantation bleeding or hormonal bleeding
What are the types of gynaecological bleeding in early pregnancy?
- Cervical: polyps, ectropion (outwards extension of the cervix towards vagina), cancer
- Vaginal: Trichomonas vaginitis, bacterial vaginosis, foreign body, vaginal tumours
- Bleeding disorders: Thrombocytopenia, haemophilia, Von Willebrand disease
- Drug induced: Heparin, Aspirin, Warfarin
What is implantation bleeding?
- Physiological bleeding you get when the fertilised egg implants on the decidua of the uterus.
- Happens 10-14 days after fertilisation.
What features of a history do you want to ascertain in an early pregnancy bleeding scenario?
Quantify bleeding: How long, Severity/quantity, Character; clots/flowing, Timing/ associated symptoms.
SOCRATES
O&G: LMP, Antenatal screens, G/P, Gynae hx, Contreceptive, Smear Hx
General Hx: Bleeding disorders, Med Hx
What features of a exam do you want to ascertain in an early pregnancy bleeding scenario?
End of the bed O-Gram: Stable?, Anaemic?, BP, HR, RR, O2 sats,
Abdo exam: Surgical pathology, Gynae pathology
Pevlic exam: Speculum, View cervic; Discharge, dilations, lesions, polyps, gestational tissue
Bimanual: Cervical motion tenderness, adnexal masses or tenderness, uterine size
Why is a speculum important?
Speculum:
View cervix for Discharge, dilations, lesions, polyps, gestational tissue
What investigations can you do for a women in early pregnancy with bleeding?
Bloods: b-hcg, FBC, Iron studies, Group and screen, Urinanalysis, Swabs, Coagulation screen
TVUSS: Location, viability, Pelvic free fluid
Assessment and resuscitation of an acutely unwell woman who
presents with pain and/or bleeding in early pregnancy?
- ABC
Discuss with on call O and G consultant/Reg - IV fluids
- Tranexamic acid
- bHCG, FBC, Group and Hold, urine, swabs
- Give 1 unit of blood if required
How do we use βHCG and ultrasound to make a diagnosis of early pregnancy viability and location?
bHCG
- Viable pregnancy bHCG levels should rise rapidly (almost doubling every 2-3 days) until 8-10 weeks. Then it should start to decline.
Ultrasound
Empty gestational sac = non-viability
If an embryo is seen with crown rump length (CRL) of 7mm or more we expect to see a heartbeat - defined as a viable pregnancy. If a heartbeat is not seen, this is sadly defined a non-viable pregnancy
What are the tx options for an expectant miscarriage?
- Wait and see, review after one week 🡪 repeat HCG then
- Advantage: natural and no medical or surgical intervention needed.
- Disadvantage: Women will go home unmonitored.
- Surgical evacuation needed if not completed by 4 weeks.
Whats the medical management for a miscarriage?
- Misoprostol (800 mcg) 🡪 give another dose if not completed by 72 hours
- Follow up USS required on day 8. If miscarriage not completed, then surgical evacuation required.
Whats the surgical management for miscarriage?
- Suction curettage: GA or local anaesthetic with sedation.
May be given buccal misoprostol (400mcg) preoperatively to soften cervix.
Advantage: Instant procedure. Woman doesn’t go home unmonitored because she is treated at hospital
Disadvantage: risk of damage to cervix, rupture of uterus, adhesions and scarring.
What specific points for their ongoing and future care will you discuss with a woman who has an
early pregnancy loss?
Miscarriage - Support and counselling.
Medical aspects:
- Vaginal bleeding can persist up to several weeks after a miscarriage. Should be advised to seek help if heavy bleeding, abdominal pain, or fever develops.
- Rhesus negative women should be administered an injection of anti D.
- Menses should resume within 6 weeks. Next pregnancy can be attempted when the patient feels emotionally ready.
What are the treatment options for management of an ectopic pregnancy?
Medical management
-IM methotrexate
Surgical management
-Laparoscopy – less blood loss, shorter duration of hospital stay
-Laparotomy
What specific points for their ongoing and future care will you discuss with a woman who has had an ectopic pregnancy terminated?
- Wait 3 months if received methotrexate
- Post surgery or expectant, wait two full menstural periods
- Recurrence 12-27%, 65% normally healthy
What is recurrent miscarriage? What is the main treatable cause of recurrent miscarriage?
- Consecutive loss of three or more early pregnancies. Occurs in 1% of couples.
- Antiphospholipid syndrome is the most treatable cause.
- Blood test needed to detect the presence of antiphospholipid antibodies to diagnose antiphospholipid syndrome
What is a molar pregnancy?
Hydatidiform mole (also known as molar pregnancy) is a subcategory of diseases under gestational trophoblastic disease, which originates from the placenta and can metastasize.
1) Complete hydatidiform mole: enucleated egg fertilized by 2 sperms. This results in only paternal DNA being expressed
2) Partial hydatidiform mole: A normal egg is fertilised by 2 sperms.
How do you manage a molar pregnancy?
- Dilatation and curettage (D and C)
- Hysterectomy
- Chemotherapy (if bHCG lvls remain elevated after above procedures
What are the indications for anti-D prophylaxis in early pregnancy?
- Chorionic villus sampling
- Miscarriage
- Abortion (medical after 10 weeks of gestation or surgical)
- Ectopic pregnancy
- Molar pregnancy
What is hyperemesis gravidarum?
Severe nausea and vomiting in pregnancy leading to weight loss, ketouria and electrolyte abnormalities
How would you distinguish between hyperemesis gravidarum and ‘normal morning sickness’?
Morning sickness normally resolves between 12-20 weeks.
Hyperemesis gravidarum is characterised by persistent vomiting, weight loss of more than 5%, ketouria, electrolyte abnormalities (hypokalaemia) and dehydration.
What features of the history and examination of a woman with nausea and vomiting during
pregnancy might indicate that admission and/or intravenous rehydration is required?
weight loss of more than 5%, ketouria, electrolyte abnormalities (hypokalaemia) and dehydration.
What are the important ‘not-to-be-missed’ diagnoses (vomiting)– both differentials and causes of serious
morbidity?
Hyperemesis gravidarum should be distinguished from other conditions that may cause persistent vomiting, such as hepatitis, pancreatitis, pyelonephritis, peptic ulcer disease, thyroid disease and adrenocortical insufficiency.
- N&V commencing after 12 weeks is unlikely to be pregnancy related.
What investigations would you consider when assessing a patient with hyperemesis gravidarum?
Justify each one.
- Midstream urine microscopy to exclude a urinary tract infection
- Ultrasound to exclude trophoblastic disease or multiple pregnancy
- TSH if there is suspicion of thyrotoxicosis
- Electrolytes and liver function tests
What are evidence-based therapies for hyperemesis gravidarum?
- Metoclopramide
- Antihistamiens
- Cyclazine
- Prochlorperazine
- Odansetron
- Pyridoxine
+/- Corticosteroids
+/- acid reducing agents
What is post-partum heamorrhage?
Primary: Blodd loss greater than 500mls through genital tract within 24hrs of birth
What are the four main causes of PPH?
Tone: Atonic uterus, Overdistended uterus, Infection, anatomical distortion i.e fibroids
Tissue: Retained placenta or cotyledon, abnormal placenta
Trauma: Genital tract lacerations, uterine rupture, uterine inversion
Thrombin: Abruption, massive blood loss, pre-eclampsia, amniotic fluid embolus, inherited/acquired bleeding disorder
What risk factors are associated for developing PPH at booking appointment and during labour?
Booking:
- 35 years
- High parity
- BMI 30+
- Prior PPH, retained placenta
- Placenta previa
- Multiple pregnancy
- Uterine fibroids
During labour:
- Prolonged labour
- Pyrexia in labour
- Augmentation with syntocinon
- Operative delivery
- Placental abruption
- Retained placenta
What plan would you put in place for a woman identified as being at increased risk of PPH?
- Active management of third stage of labour
-> Ecbolic drug
-> Cord clamping
-> Cord traction
What steps will YOU take immediately when you are called to see this patient? - a PPH pt
Call seniors
- Assess: DR ABC
- Arrest bleeding: Urinary catheter, firm massage of uterus, uterotonic drugs. If bleeding greater, GA and exam.
- Replace blood loss: Crystalloid +/- O neg
What is ‘active management of the third stage’? How does it differ from ‘physiological
management’?
Active management:
- Ecbolic drugs, cord clamping and cord tension
Physiological management:
- No drugs
- Maternal effort w/o cord clamping or traction.
- May be appropriate for women w/o risk factors.
How is heavy menstural bleeding defined?
Excessive menstrual blood loss that interferes with physical, emotional, social, and material quality of life
~30-40mls
What are the important DDX to consider in heavy menstural bleeding?
Consider:
- Anaemia / heamodynamic stability
- Pregnancy … Ectopic/miscarriage…
- Other lower genital tract pathology.. polyp, trauma etc
- Urethral or rectal origin
What are the main causes of heavy menstural bleeding?
- Uterine related
- Hormonal imbalance
- Other
What uterine related pathology can lead to heavy menstural bleeding?
1) Endometrial hyperplasia or cancer
2) Uterine fibroids (leiomyolma)
3) Uterine polyps
4) Adenomyosis / endometriosis
5) Uterine muscle dysfunction
6) Endometrial disorders
What conditions with hormonal imbalances can lead to heavy menstrual bleeding?
- PCOS
- Permimenopausal
- Underactive thyroid
What are the ‘other’ causes of heavy menstrual bleeding?
- Coagulopathies
- Medications
How is endometrial hyperplasia / cancer diagnosed?
- History + Exam
- Investigations:
-> TVUS: Endometrial size/ wall thickness =/- biopsy = Histology
What conditions are associated with HMB?
- Endometrial hyperplasia / cancer
- Uterine fibroids
- Dysfunctional uterine bleeding
How are uterine fibroids diagnosed?
Ultrasound is the diagnositc test
Can be surgically removed.
How is dysfunctional uterine bleeding diagnosed?
Diagnosis of exclusion
What are the acute tx options for HMB?
- Tranexamic acid
- Norethisterone
- Medroxyprogesterone a.k.a Provera
What are the treatment options for chronic HMB?
Hormonal:
- Mirena
- OCP
- Progestogens
- Others; Vaginal ring, injection, skin patches
Non-hormonal:
- Tranexamic acid
- NSAIDS
Surgical
- Hysteroscopy
- Laparoscopy
- Endometrial ablation
- Hysterectomy
What factors need to be taken into account when helping a patient to decide on appropriate management options for bleeding?
Important factors:
● Cause of bleeding
● Other symp that can be cross coverd.
● Other medical concerns about this patient
● Contraindications
Patient factors:
● Future family
● Do they need contraception right now?
● Patient preference
What is the role of the Mirena IUS in the management of heavy menstrual bleeding? What are the advantages?
Advantages:
- Reduces pain/ can stop perioids
● Effective contraception
● 5-10 years
● Reversible LARC
● Delivers progesterone right to where it is needed, local, avoid systemic effects (some women
are sensitive to progesterone, anxiety, low mood etc.)
● Procedure is quick (5-10 minutes)
What is the role of the Mirena IUS in the management of heavy menstrual bleeding? What are the disadvantages?
Disadvantages:
● Spotting in the first few months
● Might give some women irregular light bleeding
● Procedure which can be really painful for some women. Can have cramps/ dizziness
● Small risk of infection when it is put in (1%)
● Small risk of damage to the uterus
● Can sometimes come out by itself
When would you do a hysteroscopy for HMB?
● Look at the thickness of the endometrium in relation to the time of the cycle - if it is thick at a
time when it should be thin
● If you think it is thick because of polyps = hysteroscopy because pipelle doesn’t pick up
polyps
When explaining a smear what are the important points to explain?
1) What it is:
2) How its managed:
3) What happens if we dont do anything.
What are the histology gradings of a smear?
HGSIL: High grade squamous intraepithelial lesion - precancerous (changes consistent with CIN3)
How are abnormal cervical smears managed?
+/- Colposcopy to confirm “ A specialist examines the cells of your cervix using a special microscope called a calopscope” Its important you go even if you dont have any symptoms. ~15 mins.
HSIL: Confirmed -> treatment and follow up with yearly HPV testing and smear (return to 3 yearly if negative for 2 consecutive years)
Abnormal cells removed:
- LLETZ
- Laser
- Diathermy (Heat)
- Cone biopsy
= All under local or GA
What happens if you dont do anything for HGSIL (CIN3)?
Untreated, approximately 30% of women with HSIL (CIN 2/3) would progress to invasive cervical cancer over 10 years
What are common misconceptions about abnormal smears and how might you correct these?
Misconception: abnormal smear = cancer
● There are a range of abnormal changes and most do not mean cancer
● It is important to monitor or treat these so that they do not progress to cancer which is why
there are good management options and the screening programme can be adapted to
increase monitoring as required
● Show image so the women can see what her changes mean
What is colposcopy?
Colposcopy = visual magnified examination of the cervix with a high-powered microscope (colposcope) for the purpose of recognizing suspicious/abnormal areas for biopsy. 3-5% acetic acid is first applied to the tissue; this causes the abnormal areas to become more prominent. These abnormal areas are then viewed through the colposcope and biopsied.
When is colposcopy necessary?
● This is necessary when some abnormal results are found on cervical smear to further assess
these changes
○ LSIL smear >35, no previous abnormal smear but positive HPV test
○ HSIL
○ Genital warts
○ Other genital lesions
○ Atypical glandular cells
Discuss the various abnormal smears and managements?
What is LETZ/LEEP?
● Large loop excision of the transformation zone (LLETZ)
● Loop electrosurgical excision procedure (LEEP)
● Diathermy loop biopsy or just a loop, uses a small wire loop with an electrical current running
through it to cut away the affected area of tissue and seal the wound at the same time
● Usually for high grade squamous abnormalities
What is a cone biopsy?
● Removal of a cone-shaped area of the cervix with a scalpel
● Usually for high grade glandular abnormalities
What is the role of the HPV vaccine?
● GARDASIL 9 is indicated in females aged 9 through 45 years* for the prevention of cervical, vulvar, vaginal and anal cancer, precancerous or dysplastic lesions, genital warts, and infection caused by Human Papillomavirus (HPV)
● This vaccine is not intended to be used for treatment of active external genital lesions; cervical, vulvar, vaginal or anal cancers; CIN, VIN, VaIN, or AIN.
● Routine cervical screening and detection and removal of cervical lesions should be continued in individuals who receive the vaccine.
What is the epidemiology of cervical cancer?
● Combined worldwide incidence of almost half a million new cases annually, second only to breast cancer
● In New Zealand, about 160 women develop cervical cancer each year
● Each year approximately 25,000 abnormal smear test results among New Zealand women
○ Without cervical screening about 1 in 90 women will develop cervical cancer and one out of 200 will die from it.
○ With cervical screening about 1 in 570 will develop cervical cancer and one out of 1280 will die from it
● Note: lifetime risk for getting HPV in New Zealand is 80%
○ Most HPV cleared by the body, especially in young women (about 80-90% within 2
years of acquisition)
What are the risk factors of cervical cancer?
● Persistent HPV infection
● Genetics/FHx
● Smoking (Smokers are twice as likely as non-smokers to develop cervical cancer)
● Nutrition (diet low in fruits and vegetables have an increased risk)
● Number of sexual partners (higher number = higher risk of contracting HPV)
● Not having regular smear tests
● High number of sexual partners
● Immunosuppression
● Older age
● Early age of intercourse
● History of STI’s
● Socio-economic status
● OCP
● HIV
How does a woman with cervical cancer present?
● Abnormal vaginal bleeding (e.g post-coital, intermenstrual or post-menopausal)
● Vaginal discharge (blood-stained, foul-smelling)
● Dyspareunia
● Pelvic pain
● Weight loss
● Abnormal smear
● Renal failure, DVT, neuropathic pain
How are the cervical cancers graded?
● IA1 - confined to cervix
● IB1 - clinically visible <4cm dimension
● IB2 - clinically visible >4cm dimension
● IIA1 - involvement of vagina and paracervical tissue
● III - extends to pelvic sidewall, lower vagina or ureteric obstruction
● IV - beyond true pelvis, bladder, rectum, distant mets
How is cervical cancer treated?
Consider whether fertility needs to be preserved or not (preserves fertility)
● Cone biopsy
● Radical trachelectomy with pelvic lymph node dissection*
● Lletz procedure
● External beam radiation therapy (EBRT) to the pelvis plus brachytherapy
● Radical hysterectomy with removal of pelvic lymph nodes
● Radiation
● Chemoradiation
What are some specific cervical cancer treatments based on grading?
IA1 - Lletz, cone biopsy
IB1 - Surgery
● Radical hysterectomy + pelvic lymphadenectomy
● Trachelectomy (fertility sparing)
IB2 - IV - chemoradiation
How are gynae cancers treated and how do these differ from cervical cancers?
Gynae cancers
● Radiation
● Chemotherapy
● Surgery
Differs from other gynae cancers because its spread is local so a hysterectomy is a radical hysterectomy which includes taking the top of the vagina.
What is the minimum rate of cervical dilation?
0.5cm an hour.
VE done every four hrs so 2cm every four hrs
