O&G Things I Don't Know xoxo Flashcards
define miscarriage?
pregnancy loss <24 weeks gestation
how common is miscarriage?
1 in 5
caues of miscarriage?
geentic infection uterine anomalies immunological (eg thrombophilia, SLE) unexplained
how can miscarriage present?
pain (usually crampy)
bleeding
sepsis
how can miscarriage be diagnosed?
not on 1st scan if gestational sac <25mm or crown-rump length <7mm
would need to bring them back in 1 week time to confirm
if over these measurements, then 2 sonogrophers can confirm miscarriage on US
how is miscarriage managed?
expectant - up to 14 days
medical - misoprostol
surgical - evacuation of uterus
when is anti-D required in miscarriage?
Rh negative and over 12 weeks
or under 12 weeks and intrauterine something??????
what is ectopic?
pregnnacy outside womb (95% in tube)
risk factor for ectopic?
smoker
PID
previous ectopic
previous tubal surgery
how is pregnancy of unknown location monitored if stable?
check HCG 48 hrs apart
- > 63% rise = likely IUP and offer USS
- if >50% drop, likely a failing pregnancy (wherever it is) and should do another pregnancy test in 14 days
1st line management for ectopic if stable?
expectant (if likely to attend follow up - twice weekly HCG and weekly USS)
when can expectant management be used for ectopic?
HCG <1500 and dropping
so significant pain
empty uterus
mass <35mm and no FH
medical management of ectopic?
methotrexate
when is methotrexate best used for ectopic?
best if HCG <3000 (but can be used up to 5000)
risks of methotrexate?
bone marrow suppression (infections), pulmonary fibrosis, liver cirrhosis, renal failure and gastric ulcers
cant get pregnant for a while afterwards (6 months maybe?)
surgical management of ectopic?
salpingectomy or salpingotomy
salpingectomy (removal of whole tube) if normal contralateral tube
salpingotomy (removal of just the ectopic) if the other tube is abnormal to preserve fertility
risks of salpingotomy?
some tissue is left behind in 10% of cases (persistent trophoblastic disease) which would need further intervention
how does molar pregnancy usually present?
irregular bleeding
hyperemesis
hyperthyroid
how is response to methotrexate monitored in medical management of ectopic?
do bloods (HCG?) on day 4-7 afterwards
which type of molar pregnancy is diploid?
complete (duplication of haploid sperm following fertilisation of empty egg)
which mole is triploid?
partial (2 sets paternal and 1 set maternal genes - 2 sperm + 1 egg)
karyotype of partial vs complete mole?
partial = 69 XXX/XXY/XYY complete = 46 XX
what causes hyperemesis in molar pregnancy?
extremely high HCG
what causes hyperthyroidism in molar pregnancy?
HCG has similar structure to TSH
how long after a molar pregnancy do you have to wait before getting pregnant again?
6 months if HCG normal
1 year if chemo was needed
who are fibroids more common in?
pre-menopausal (fed by oestrogen)
management of fibroids under 3cm (if no distortion of uterine cavity)?
mirena coil = 1st line tranexamic acid and NSAIDs COCP progesterone only contraception surgery unlikely to be needed but may be done via transcervical resection of submucosal fibroids, endometrial ablation or hysterectomy as last resort
first line management of fibroids over 3cm?
tranexamic acid + NSAIDs
other management options in fibroids over 3cm?
mirena coil COCP progesterone only methods uterine artery embolisation myomectomy hysterectomy
what surgical methods can be used for fibroids >3cm that arent used for smaller ones?
uterine artery embolisation
myomectomy
what might be given before surgery for fibroids and why?
GnRH analogues can shrink fibroids and reduce bleeding
can be used for 3 months prior to surgery
how is a simple ovarian cyst in a PRE-menopausal woman managed if asymptomatic?
no need for Ca125
<5cm = discharge
5-7cm = repeat US scan in 12 months
»7cm = offer surgery (risk of torsion)
how is a simple ovarian cyst managed in a PRE-menopausal woman if symptomatic?
offer surgery regardless of size
how is a complex cyst managed in a pre-menopausal woman?
Ca125
AFP, bHCG, LDH (if under 40)
how is Ca125 used in a complex ovarian cyst in pre-menopausal woman?
<200 = probs endometriosis or fibroids - refer to general gynae >200 = refer to gynae oncology MDT
signs of a complex ovarian cyst on US?
solid areas
multicystic
capillary projections
etc
how are ovarian cysts investigated in post-menopausal women?
always abnormal in post-menopause
need to calculate RMI
- RMI <200 = low risk
- RMI >200 = CT chest, abdo, pelvis and refer to gynae oncology
how is a low risk ovarian cyst (RMI <200) managed in post-menopausal woman?
if <5cm and simple - repeat USS and Ca125 in 3 months and every 3 months for 1 year, if still unchanged after 1 year can be discharged
if low risk but not simple then offer surgery
who gets cervical screening?
25-64 year olds
routine recall for cervical screening?
5 years
whats done if HPV positive on cervical screen?
cytology
whats done if cytology positive/negative on cervical screen?
positive = colposcopy negative = another HPV test in 12 months (back to routine recall if this is negative or back to cytology etc if still positive)
risks of HRT?
VTE
stroke
CVS (if over 60)
breast cancer (if combined)
does transdermal HRT have same risks?
no
no increased risk of VTE or stroke etc
when can oestrogen only HRT be used?
only if theyve had a hysterectomy (increased endoemetrial cancer risk)
when is cyclical HRT used?
menopausal symptoms but still having periods (useful to maintain regular period so you know when its coming and can tell more easily when they naturally stop)
can be taken on monthly cycle or 3 monthly cycle (take oestrogen daily then progesterone for last 14 days in both types)
when is continuous HRT used?
post-menopausal women (not had period for over 12 months)
take oestrogen and progesterone every day
are pelvic floor exercises used for all cases of prolapse?
yes
either alone or alongside other things
when is surgery definitely needed in prolapse?
if pelvic organs coming to interoitus or below
types of surgery in prolapse?
anterior repair (cystocele) posterior repair (rectocele) sacrospinous fixation (can be done under LA) laparoscopic sacrohysteropexy/colpopexy = needs GA so often done in younger patients with fewer co-morbidities colpoclesis (completely closes vagina)
POP-Q staging of prolapse?
basically hymen = 0
-1, -2 etc means above the hymen (still inside)
+1, +2 etc means below hymen (coming out)
stage 0 = no prolapse
stage 1 =
how is prolapse managed according to stage?
stage 0-1 = pelvic floor exercise alone
stage 1 = exercise and pessary
stage 2 onwards = think about surgery
possible complications of long term pessary?
vaginal discharge
ulceration (may lead to vesico-vaginal or rectovaginal fistulae)
formation of fibrous bands attaching the pessary to the vagina
how often should pessaries be changed?
every 6 months
should assess vaginal mucosa at that time - leave pessary out a while and give vaginal oestrogen if mucosal ulcers seen
investigations in incontinence?
urinalysis in everyone urodynamics bladder diary post void residual volume cystoscopy
management of stress intontinence?
conservative = weight loss, pelvic floor exercises, incontinence ring (not used much?) medical = vaginal oestrogen, duloxetine (NEVER USED SO BASICALLY FORGET ABOUT IT) surgical = bulking agents injected into bladder neck, fascial sling, colposuspension
conservative management of overactive bladder?
weight loss
reduce caffeine
bladder retraining
medical management of overactive bladder?
anticholinergics - tolteradine/soliphenacin (oxybutynin not used as much these days due to bad anti-cholinergic side effects)
beta-3 adrenoceptor agonist - mirabegron (newer, no anti-cholinergic side effects, but can cause rise in BP so not as good if already hypertensive)
desmopressin (can be good for nocturia but dual therapy with anti-cholinergic + mirabegron usually enough)
vaginal oestrogen also given often
risks with anti-cholinergics
side effects (need to discuss with patient) many stop taking due to side effects
when does lichen sclerosis usually present?
post-menopausal
features of lichen sclerosis?
severe itching trauma and skin splitting from excoriation loss of architecture fissuring figure of 8 distribution fusion silver white labia minora and clitoris can even disappear
how is lichen sclerosis managed?
avoid irritants
ultra-potent steroid (dermovate) for 6 weeks cures most women
what complications occur within 24 hrs of surgery?
primary haemorrhage
UTI
what complications occur between 1-5 days after surgery?
infection
thrombosis
direct injury (visceral perforation)
what complications occur between 7-14 after surgery?
infection
DVT (more common at 7-14 days than 1-5 days)
indirect injury (eg avascular necrosis secondary to diathermy)
