Obstetrics Revision 1 Flashcards
Describe the pathophysiology of atrophic vaginitis [2]
Reduction in levels of oestrogen in the body:
- The vaginal mucosa becomes drier, thinner and more easily broken, which can lead to epithelial irritation and inflammation
- levels of glycogen production in the vagina fall, leading to a decrease in the numbers of lactobacilli which normally maintain the acidic environment of the vagina. Their absence allows an increasingly alkaline environment in which infection is more likely to develop
Describe the internal [4] and external [4] examination findings of atrophic vaginitis
External examination
* Reduced pubic hair
* Loss of labial fat pad
* Narrowing of vaginal introitus
* Thinning of labia minora
Internal examination
* Smooth, shiny vaginal mucosa with loss of skin folds
* Dryness of mucosa
* Loss of vaginal muscle tone
* Erythema or bleeding
Describe how you treat atrophic vaginitis [3]
Vaginal lubricants and moisturisers
Topical oestrogens
* Treatments will take around 3 weeks to have any effect, with maximal effect noticeable within 3 months of starting
* Long-term topical oestrogens are considered safe, with no effect on endometrial proliferation
Systemic HRT
* Can be used in patients with other post-menopausal symptoms
* Up to 25% of patients taking systemic HRT will also experience vaginal dryness, so may require topical oestrogens in addition.
Describe the pathophysiology of a Bartholin’s cyst and then abscess
A Batholin gland cyst:
- A duct of one of the Bartholin glands becomes obstructed due to trauma, inflammation or infection
- An accumulation of secretions within the gland leading to cyst formation. This is known as a Bartholin’s cyst.
A Batholin gland abscess:
* Bacteria then infect the cyst; include Escherichia coli, Staphylococcus aureus, and sexually transmitted infections such as Neisseria gonorrhoeae and Chlamydia trachomatis.
* If not drained or treated promptly, pus accumulates leading to abscess formation.
Describe the clinical features of Bartholin’s abscess [5]
Swelling:
* Patients often present with a unilateral, tender swelling at the lower vestibule near the vaginal opening. The size of the swelling may vary from a small nodule to a large mass occupying a significant portion of the labium majus.
Pain:
* The affected area typically exhibits localized pain that may be exacerbated by walking, sitting, or engaging in sexual activity.
* In some cases, patients may report dyspareunia due to increased pressure on the abscess during intercourse.
Erythema and warmth:
Fluctuance:
* Upon palpation, a fluctuant mass may be appreciated, indicating pus accumulation within the abscess cavity.
Pus discharge:
* Spontaneous rupture or incision and drainage of the abscess can lead to purulent discharge from the external opening.
NB: fever and malaise alsoo occur
The management depends on the size of the cyst and presence or absence of an abscess.
Describe the management of small (< 3cm) [1] and large (> 3cm) [3] large cysts
Small cysts (< 3 cm):
- No specific management is required for small asymptomatic cysts
- Symptomatic cysts may be managed with warm compresses or bath
Large cysts (≥3 cm) or abscess:
- Marsupialisation: incision into the cyst or abscess and suturing the edges of the skin to create a permanent opening; The stitches should dissolve over four weeks.
- Word Catheter Placement: placement of a small plastic tube with an inflatable balloon; done under local anaesthetic and usually remains for 4 weeks and then removed
Antibiotics are generally reserved for patients with recurrent abscess, systemic features (e.g. fever, rigors), complicated infection (e.g. immunosuppressed, extensive cellulitis), or resistant organisms (e.g. MRSA).
NB: Gland Excision: Reserved for recurrent cases that do not respond to other treatments, this procedure involves complete removal of the Bartholin’s gland. However, due to significant postoperative morbidity associated with this procedure, it is typically considered as a last resort.
What are complications of Bartholin’s abscess [4]
Recurrent Bartholin gland abscesses
Fistula formation: Chronic inflammation and recurrent infections may lead to fistula formation between the abscess cavity and the skin or vaginal mucosa.
Cellulitis
Abscess extension: In severe cases, the abscess can extend to adjacent structures such as the perineum, buttock, or anterior abdominal wall.
Define what is meant by a uterine fibroid (leiomyomas) [1]
What are the three types? [3]
Uterine fibroids (leiomyomas) are benign tumours that arise from the muscle layer of the uterus termed the myometrium
- Depending on the location of fibroids, they may be classified as subserosal, intramural or submucosal.
There are several risk factors that increase the chances of a female developing fibroids.
Name 4 [4]
Early age of puberty
Increasing age
Obesity
Ethnicity (e.g. black females)
Describe the management of fibroids [+]
Menorrhagia is the most common problem associated with fibroids and thus management focuses on the treatment of heavy periods:
- Levonorgestrel-releasing intrauterine system (Mirena) - 1st line
- COCP
- NSAIDS
- TXA
Surgical intervention:
- Endometrial ablation
- Myomectomy or hysterectomy
- Uterine artery embolisation (for large fiboids)
Describe the signs and symptoms of fibroids [6]
Menorrhagia (most common) and dysmenorrhoea
Sub/Infertility, if the fibroid is large enough to distort the uterine cavity
Deep dyspareunia (pain during intercourse)
Bloating or feeling full in the abdomen
Abdominal pain, worse during menstruation
Urinary frequency if large enough and putting pressure on the bladder
NB: Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
Which medications can be used to reduce the size of fibroids prior to surgery? [2]
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap)
- They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.
Endometrial ablation can be used to destroy the endometrium.
Name a type of endometrial ablation that is most commonly used? [1]
Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation
- This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus.
Describe what is meant by ‘red’ degeneration of fibroids [1]
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
Describe which type of fibroids typically undergo ‘red’ degeneration [1]
Describe why this occurs
Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy
- Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic
- It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.
NB: most commonly occurs in the 12th - 22nd week of pregnancy
TOM TIP: Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be []
TOM TIP: Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
Describe the typical presentation of fibroid degeneration / red degeneration [+]
Acute abdominal pain during pregnancy
- Constant abdominal pain localising to the area of the fibroid
- Area tender to palpation
- Rebound tenderness
- Fibroid likely palpable as it enlarges
A low-grade fever commonly accompanies fibroid degeneration
There should be no haemodynamic compromise or increased oxygen requirement in simple acute fibroid degeneration
Vaginal bleeding is NOT a common feature of degeneration and should prompt suspicion of other conditions such as placental abruption.
Describe the management of fibroid degeneration
The mainstay of treatment is conservative management. The patient will need to be assessed at a centre with obstetrics care
Patients should be reassured that fibroids usually regress during the puerperium owing to hormonal withdrawal.
Analgesia
- Acute painful episode usually resolves in 4-7 days
- Paracetamol
- NSAIDS should be used with caution to avoid fetal complications such as premature closure of the ductus arteriosus
In very rare cases, the decision may be made to remove fibroids in the first or second trimester of pregnancy:
- Fibroids causing intractable pain or a torted pedunculated fibroid are rare indications
Why do GnRH agonists shrink fibroids?
Describe the different types of myomectomy [3] as if to a patient
Abdominal Myomectomy
* In an abdominal myomectomy, an incision is made in the abdomen (which may be around 12 cm or less).
* This enables the doctor to reach the uterus so that the uterine fibroids can be removed from the wall of the womb (intramural) and the outer layer of the womb (subserous).
* Once the fibroids have been removed the uterus and abdomen are stitched up. You will be given a general anaesthetic for this procedure. You can expect to stay in hospital for 3-4 days.
Laparoscopic Myomectomy
* We can sometimes remove smaller fibroids using keyhole instruments passed through tiny cuts in your abdomen.
* This is called a laparoscopic myomectomy or laparoscopic resection.
* A laparoscope (a narrow tube with a fibre optic light) is inserted into the womb through a tiny cut in the abdomen.
* Other small cuts are made in the same area to insert instruments that can dissect and remove the fibroids. You will be given a general anaesthetic for this procedure. You can expect to stay in hospital for 1-2 days.
Hysteroscopic Myomectomy
* A hysteroscopic myomectomy (or hysteroscopic resection) is where a small hysteroscope is inserted through the vagina and the cervix, so that one or more fibroids can be removed.
* This procedure can only be done where there are small fibroids which are just underneath the uterine lining (submucous fibroids).
* You will be given a local or general anaesthetic and will probably be able to go home the same day.
Lecture
With regards to menorrhagia - how heavy is too heavy? [6]
- Flooding
- Clots - especially larger than 50p coin
- Changing pads 1-2hourly
- Double super pad and tampon
- Expelling tampons/coils
- Quality of life
The most common type of cervical cancer is []
The most common type of cervical cancer is squamous cell carcinoma.
Describe the pathophysiology of cervical cancer [4]
1. HPV infection from HPV 16 and 18
2. HPV produces proteins E6 and E7; which inhibits the tumour suppressor genes P53 and pRb (E6 - P53; E7 - pRb); this initiates cell cycle progression
3. Cervical Intraepithelial Neoplasia (CIN) occurs (CIN1: self limiting; CIN2 & 3: can lead invasive carcinomas)
4. Can lead to invasion of malignant cells through the basement membrane into underlying stroma.
.
White cervical cells after staining in colposcopy would indicate which test has been performed? [1]
What would this indicate? [1]
Acetic acid causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.
What staining has been used on this cervix? [1]
Which test / stain has been performed? [1]
What does this indicate? [1]
Schiller’s (Lugol’s) iodine test involves the application of an iodine-based solution. As the iodine solution is glycophilic, normal glycogen containing squamous epithelium stains brown or black
- CIN and invasive cancer has little glycogen and does not stain. Columnar epithelium is also deficient in glycogen so does not stain.
Describe what is meant by a cone biopsy [1] and when it is indicated [1]
A cone biopsy is a treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer.:
- The surgeon removes a cone-shaped piece of the cervix using a scalpel
- This sample is sent for histology to assess for malignancy.
Describe the different stages of cervical cancer [4]
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina but not lower 1/3 or vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 1B-2A is? [2]
Stage 1B – 2A:
- Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 2B-4A ? [1]
Stage 2B – 4A:
- Chemotherapy and radiotherapy
- Radiotherapy may either be bachytherapy or external beam radiotherapy
- Cisplatin is the commonly used chemotherapeutic agent
Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 4B ? [1]
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
In which instances would you test again at 12 months? [1]
