OBGYN Flashcards
At what week can US detect pregnancy?
US can detect pregnancy at 6 weeks.
What is the B HCG level at which a gestational sac can be seen in transvaginal US?
Gestational sac seen in transvaginal US with B HCG > 1,500.
Fetal pole: B HCG 6,000
Classification of spontaneous abortions
Missed: 1st trimester bleeding, closed os, sac on ultrasound, no heartbeat
Threatened: 1st trimester bleeding, heartbeat
Incomplete: tissue protrudes through os
What are the leading diagnoses for a premenopausal female patient with pelvic pain?
1 ectopic pregnancy, #2 hemorrhagic ovarian cyst, #3 PID, #4 appendicitis, #5 adnexal torsion.
Mittelschmerz: rupture of Graafian follicle, pain that can be confused with appendicitis; 14 days after 1st day of menses
What is the purpose of ovarian cystectomy?
Removes mass and preserves ovary; used for benign conditions or if diagnosis is uncertain.
When is salpingo-oophorectomy used?
Used for cancer or non-viable ovarian tissue after torsion.
What indicates a strongly suspected ectopic pregnancy?
If no sac is seen and BHCG is > 3000.
MC site: ampullary portion of Fallopian tubes
What is the treatment for stable ectopic pregnancy?
If stable, treat with MTX (methotrexate).
What is the treatment for unstable ectopic pregnancy?
If unstable, go to OR; unruptured and stable - salpingotomy- evacuate hematoma, repair tube VS just methotrexate; ruptured or unstable - salpingectomy (remove fallopian tube)
What are the contraindications to MTX in ectopic pregnancy?
BHCG > 5,000.
What should be done for a female presenting with pelvic pain?
Start with US with Doppler first; will see absent blood flow to ovary in Adnexal (ovarian) torsion.
Get a qualitative BHCG first, if positive (think ectopic pregnancy) then get quantitative
What is the most common cause of adnexal torsion?
MCC by a tumor in the ovary; presence of adnexal mass should raise suspicion of torsion.
What is the treatment for a necrotic ovary due to torsion?
If necrotic, perform salpingo-oophorectomy.
Always check to see if ovary recovers try your best to preserve ovary
What are the risk factors for tubo-ovarian abscess?
Previous PID, IUD in place.
How is a tubo-ovarian abscess diagnosed?
Cervical motion tenderness and adnexal mass on exam.
- Get BHCG to rule out ectopic
- US for Dx: if Abscess is > 6 cm requires percutaneous drainage
What is the treatment for a tubo-ovarian abscess if stable and non-ruptured?
IR drainage if > 6 cm; doxycycline and ceftriaxone for antibiotics.
Only operate if ruptured or life threatening or failed drainage; just drain abscess, no drains, NO OOPHERECTOMY
What is the most common site for endometriosis?
MC site: ovaries.
Endometriosis – blue mass. Tx: OCP, danazol
What is the most common type of vaginal cancer?
MC type: squamous.
XRT used for most cancers of vagina
What can Diethylstilbestrol (DES) cause?
Can cause clear cell carcinoma.
What is the treatment for Botryoides rhabdomyosarcoma in young girls?
Grape-like mass
Treatment: resect.
What is the treatment for vulvar cancer?
-MC SCC. Goes to inguinal nodes
-Stage 1 (< 2 cm): WLE (2 cm margin) ipsilateral inguinal and femoral node dissection.
-Stage 2 (> 2 cm): Modified radical vulvectomy; remove bilateral labia major, minora, clitoris, with bilateral inguinal/femoral node dissection. Postop XRT if close margins (< 1 cm)
-Paget’s, VIN III or higher, carcinoma in situ - all premalignant; treatment: WLE (0.5-1 cm margins), laser ablation, or topical imiquimod
What does OCP increase the risk of?
Increases risk of cancer of: breast, cervical.
What does OCP decrease the risk of?
Decreases risk of cancer of: endometrial and ovarian.
What is the second most common cause of gynecologic death?
Ovarian cancer; #1 is endometrial.
What is the most common type of endometrial cancer?
MC type: endometrial adenocarcinoma.
What is the diagnosis method for endometrial cancer?
Endometrial curettage or brush biopsy.
What is the treatment for stage I endometrial cancer?
Stage I – endometrium
TAH and BSO.
What is the treatment for stage II endometrial cancer?
Stage II - cervix
TAH and BSO, para-aortic and pelvic LN dissection, and post-op XRT.
What is the treatment for stage III endometrial cancer?
Stage III – vagina, peritoneum and ovary
TAH and BSO, para-aortic and pelvic LN dissection, and post-op XRT.
What is the treatment for stage IV endometrial cancer?
Stage IV – bladder and rectum
TAH and BSO, para-aortic and pelvic LN dissection, and post-op XRT.
What is cervical cancer associated with?
Associated with HPV 16, 18.
HPV 6 and 11 = warts
What is the most common type of cervical cancer?
Squamous cell is MC.
Goes to obturator nodes first
What does a Pap smear look for?
Looks for intraepithelial neoplasia or dysplasia. if present: need Colposcopy biopsy
Colposcopy biopsy – does not biopsy entire cervix, only small part. Invasive cancer can’t be ruled in or out with this
What is the treatment for CIN 1?
Cervical intraepithelial neoplasia 1 (CIN 1) = mild dysplasia
Repeat pap smear in 1 year.
What is the treatment for CIN 2?
CIN 2 = moderate dysplasia
Need either cryoablation/laser ablation or excision for treatment.
What is the treatment for CIN 3?
CIN 3 = high grade dysplasia
Need either cryoablation/laser ablation or excision for treatment.
if high grade CIN or more invasive found: need conization (inner lining of cervix removed) If no BM penetrated you are done
What is the treatment for microscopic disease without basement membrane invasion?
Cone biopsy (inner lining of cervix removed).
What is the treatment for stage I and IIa cervical cancer?
Stage 1: Cervix
Stage 2: upper 2/3 of vagina
TAH and pelvic LN dissection.
What is the treatment for stage IIb or higher cervical cancer?
Stage 3: pelvis, side wall, lower 1/3 of vagina; hydronephrosis
Stage 4: bladder and rectum
IV chemo-XRT (Cisplatin and paclitaxel)
-If that fails need pelvic exenteration (TAH-BSO, take vagina, rectum, bladder)
What is the treatment for incidental ovarian cyst/tumor found intra-op in premenopausal women?
If simple cyst, < 5 cm, do not touch this intra-op.
What is the treatment for complex cyst or > 10 cm found intra-op in postmenopausal women?
Consider removal vs do nothing; perform laparoscopic oophorectomy -> path.
-If CA: LEAVE ALL further procedure (TAH BL oophorectomy) for GYN to deal with post op
What is the treatment for PCOS?
Clomiphene.
What is the treatment for uterine leiomyomas (fibroids)?
OCP.
Ligaments
Round ligament: allows ante version of uterus
Broad ligament: contains uterine vessels
Infundibular ligament: contains ovarian artery, nerve, vein
Cardinal ligament: holds cervix and vagina
Ovarian cancer
-MC found in post-menopausal women
-Decreased risk with: OCP and BL tubal ligation
-Increased risk with nulliparity, early menarche, late menopause
-Sx: abdominal or pelvic pain; change in stool or urinary habits; vaginal bleeding
-Diagnosis is often delayed. 60% found at stage III
-Dx: US and CA-125; diagnostic laparoscopy
Types of Ovarian Cancer
-Choriocarcinoma (BHCG)
-Struma ovarii (thyroid tissue)
-Sertoli-Leydig cell (androgens, masculinization)
-Teratoma
-Granulosa-theca (produces estrogen, precocious puberty)
-Mucinous, serous, papillary
Worst prognosis: Clear cell type
Best prognosis: malignant germ cell tumor
Ovarian Cancer Stages
Stage I: one or both ovaries/fallopian tubes.
Stage II: limited to pelvis.
Stage III throughout abdomen or positive nodes
Ovarian Cancer Treatment
Stage IV distant mets.
Tx and staging for all stages:
- Total abdominal hysterectomy + BL Salpingo-oopherectomy
- Plus pelvic and para-aortic LN sampling, Omentectomy, 4 quadrant wash out
- Debulking of any tumor left (cytoreductive surgery)
- Followed by chemo; cisplatin and paclitaxel, IV and intraperitoneal
- Cytoreduction (debulking) is affective here
Krukenberg tumor
Stomach CA that has metastasized to ovary; signet ring cells
Meige’s syndrome
Pelvic ovarian fibroma that causes ascites and hydrothorax (MC on Right)
Excision of tumor cures syndrome
Endometrial cancer
MC gynecologic CA
Risk factors: nulliparity, late 1st pregnancy, obesity, tamoxifen, unopposed estrogen
Vaginal bleeding in postmenopausal patient is endometrial cancer until proved otherwise
Uterine polyp has low chance of CA
Abdominal approach with surgery (not trans-vaginal)
Vaginal, cervical, endometrial, testicular/ovarian CA nodes
Vaginal CA, and cervical CA goes to internal iliac (obturator) nodes first
Endometrial and testicular/ovarian CA - para-aortic nodes
Post menopausal ovarian cyst
*Postmenopausal: Much lower threshold to remove ovary if post menopausal
If complex cyst: septated, has increased vascular flow on Doppler, solid component, or has papillary projection: laparoscopic oophorectomy with intra-op frozen section
if ovarian CA: convert to open TAH with contralateral oophorectomy
If simple cyst: follow with US
Premenopausal ovarian cyst
If thought to be benign but causing symptoms just remove cyst and NOT ovary cystectomy
If thought to be malignant laparoscopic oophorectomy with intra-op frozen
