O&G Revision Lecture Flashcards
what is a miscarriage
loss of pregnancy <24 weeks
most common causes of miscarriage
trisomy (50%)
uterine anomalies
immunological
unexplained
when do you start investigating the cause of miscarriage
if they’ve had >3
presentation of miscarriage
bleeding
pain
septic
when can’t you diagnose a miscarriage on USS
can’t diagnose on 1st scan if
gestational sack <25mm
crown rump length <7
instead rescan in 7-10 days
what can you diagnose a miscarriage on USS
gestational sack >25mm
crown rump length >7
confirmed by 2 sonographers
what are the 3 management options for miscarriage
expectant
medical
surgical
what is expectant management of miscarriage
wait up to 14 days - body deals with it itself
medical management of miscarriage
misoprostol
surgical management of miscarriage
evacuation of uterus
when do you give anti-D in miscarriage
if Rh -ve and over 12 weeks or <12 weeks and had uterine instrumentation
what is a threatened miscarriage
any bleeding in pregnancy
what is an inevitable miscarriage
open os and pregnancy still inside
what is an ectopic pregnancy
pregnancy outside of uterus - most commonly in uterine tube
risk factors for ectopic pregnancy
smoking
pelvic inflammatory disease
previous tubal surgery
previous infection
how do you investigate a pregnancy of unknown location
check HCG 48 hours apart if stable or can’t see pregnancy
should have >63% rise in HCG over 48 hours
if >50% drop - likely a failing pregnancy - check urine pregnancy test in 14 days
Management options for ectopic pregnancy
Expectant
medical
surgical
when can you manage an ectopic pregnancy expectantly
HCG <1500 and dropping
no significant pain
empty uterus
mass <35mm
how and when do you manage an ectopic pregnancy medically
HCG <3000
methotrexate
monitor bloods - on day 4 theres a rise in HCG which goes by day 7
if HCG hasnt dropped then give second dose
what is the surgical management of ectopic pregnancy
salpingectomy (removal of tube) v salingotomy (just ectopic)
what is a molar pregnancy
abnormal fertilisation - entirely fetal origin
how does molar pregnancy present
expressed HCG
irregular bleeding
hyperemesis
hyperthyroidism
two types of molar pregnancy
complete - sperm fertilises empty egg
partial - two sperm fertilise one egg
how does a complete molar pregnancy present on USS
(1 sperm with empty egg)
snowstorm appearance
large intrauterine cystic mass
how is complete molar pregnancy treated
always needs surgical evacuation
how does partial molar pregnancy present
2 sperm fertilising 1 egg
medical management if large fetal tissue
how long do you need to wait after a molar pregnancy before trying to conceive
6 months
1 year if needed chemo
what are fibroids
benign tumours of myometrium
what is a pelvic mass in post-menopausal women until proven otherwise
cancer
types of fibroids
subserosal -under serosa outside of uterus intramural -in the muscle submucosal -in mucosa under lining - can distort the cavity
presentation of fibroids
50% asymptomatic
heavy menstrual bleeding
dysmenorrhoea
pressure effects (frequency, retention, hydronephrosis)
infertility
can transform into leimyosarcoma
complications of fibroids
anaemia
degeneration
torsion if pedunculate
infection
how are fibroids diagnosed
USS
management of fibroids <3cm
1st line - mirena coil
2nd line - tranexamic acid and NSAIDs
combined pill POP transcervical resection endometrial ablation hysterectomy
management of fibroids >3cm
tranexamic acid and NDAIDs
Mirena coil
uterine artery embolisation
myomectomy
hysterectomy
what medication do you give for 3 months pre-op for fibroid surgery
GnRH analogues
reduces size of uterus/fibroids by turning off hormones to them
Most common type of simple pre-menopausal cyst <5cm
follicular cyst
how do you manage a simple cyst in a premenopausal woman
no need for Ca125
if asymptomatic and <5cm discharge
if 5-7cm repeat scan in 12 months
if >7cm offer surgery - risk of ovarian torsion if it gets too big
how do you manage complex fibroids in pre-menopausal women
Ca 125
if <200 - probs benign
>200 - cancer?
if <40 years old do AFP, bHCG and LDG to look for germ cell tumours
how do you manage post menopausal ovarian cysts
always abnormal - calculate RMI calculation of cancer risk
how do you calculate RMI
USS X menopausal status x Ca125
how do you treat an ovarian cyst in a post menopausal women with an RMI of <200
if cyst <5cm and simple - repeat USS in 3 months
if low risk but complex cyst - consider surgery
how do you manage an ovarian cyst in a post menopausal woman with an RMI of >200
CTCAP
refer to oncology MDT
how do you decide which cervical screening samples get cytology
only the the HPV+ ones
when can you diagnose menopause
if they’ve not had a period in >1 year
average age of menopause
51
symptoms of menopause
hot flushes night sweats joint and muscle pain vaginal dryness mood changes lack of interest in sex
when do you give oestrogen only HRT
only if no uterus
what do you give normally for HRT and why
combined oestrogen and progesterone
unopposed oestrogen increases the risk of endometrium cancer
what is a prolapse
herniation of pelvic or abdominal organs through vaginal canal
types of organs
cystocele
rectocele
uterine prolapse
vaginal vault prolapse (top of vagina prolapses after hysterectomy)
most common type of prolapse
51% of post menopausal women have an anterior vaginal wall prolapse
prolapse presentation
heaviness or dragging in the vagina
urinary symptoms
faecal incontinence
excessive straining
sexual dysfunction
how are prolapses graded
○ Classify prolapse - in relation to hymen
§ Stage 0 - no prolapse
§ Stage 1- leading edge is -1cm or above
§ Stage 2 - leading edge is between -1 and +1cm
§ Stage 3- Leading edge is +1cm or below but without complete eversion
Stage 4- complete vaginal eversion
management of prolapse
conservative
-lifestyle advise, supervised pelvic floor exercises, vaginal oestrogen
pessaries
surgery
- anterior repair
- posterior repair
- sacrospinous fixation
- laparoscopic sacrohysteroplexy
- colpocleisis - closing vagina
what is lichen sclerosis
severe itching and epidermal atrophy of the vulva of unknown aetiology
presentation of lichen sclerosis
loss of architecture fissuring figure of 8 distribution around the cliteris fusion silver white
treatment of lichen sclerosis
avoid irriants
only use soap substitures
dermuvate - ultrapotent steroids - in 6 week blocks
90-95% symptoms improve
post op Gynae complications at 0-24 hours
primary haemorrhage (tachycardia, hypotensive) - most common
UTI (pyrexia >38)
24hrs -5 days post op complications
infection (pelvis, chest, urine)
thrombosis (DVT, PE)
direct injury )visceral perforation)
7-14 days post op complications
infection (wound, pelvis, chest, urine)
thrombosis (DVT,PE)
Indirect injury (diathermy injury causing necrosis)
