PROLOG: Gynecology Flashcards
1
Q
Ultrasound findings concerning for ovarian cancer (5)
A
2
Q
What is the initial first-line treatment for hemorrhage after a D&C?
A
Uterine massage + uterotonics
3
Q
You are about to perform a LAVH on a 48 yo with a fibroid uterus. You place your camera port in the umbilicus with the assist of a Veress needle. Where do you place your accessory trocars?
A
The lower quadrant ports are placed approximately 2 cm medial and at or superior to the ASIS, lateral to the border of the rectus
The inferior epigastrics typically lie 3.7 cm from the midline at the level of the ASIS. By placing the trocar lateral to this, one can avoid these vessels.
4
Q
EMB samples approximately ___% of the endometrial cavity.
About ___% of patients noted to have complex hyperplasia have concomitant endometrial cancer.
An EMB has a failure rate of detecting cancer of ___%.
A
5-15%
30-40%
0.9%
5
Q
Ovarian Tumors and their associated positive tumor markers
Dysgerminoma
Endodermal Sinus
Granulosa Cell
Choriocarcinoma
Immature Teratoma
Embryonal Carcinoma
Epithelial Ovarian cancers
A
6
Q
A 28 yo G0 undergoing an infertility evaluation. She had a prior HSG that demonstrated tubal patency. What is the MOST appropriate test for evaluating her endometrium for polyps?
A
Saline infusion sonogram (SIS)
7
Q
Mullerian Anomalies
A
8
Q
A
Leiomyoma: Hypoechoic, well-circumscribed round masses with posterior acoustic shadowing
9
Q
Early Pregnancy Loss: Diagnosis
A
10
Q
MOA: Mifepristone
A
Derivative of norethindrone (anti-progesterone): binds to progesterone R with greater affinity than progesterone but does NOT activate the R
>> Decidual necrosis, cervical softening, increased uterine contractility, increased prostaglandin sensitivity
The uterine contractility increases 24-36 h after mifepristone administration. At this point, the sensitivity of the myometrium to the stimulatory effects of exogenous prostaglandins, like misoprostol, increase fivefold.
11
Q
Most effective medical regimen for EPL
A
Mifepristone + misoprostol
Mifepristone 200 mg PO 24 hr then 24-48 h later > misoprostol 800 mcg buccally / vaginally
12
Q
Most common surgical procedure performed for treatment of stress urinary incontinence
A
Midurethral sling
13
Q
How to manage an expanding vulvar hematoma?
A
Incise and ligate bleeding vessels
Pressure should then be maintained over the site of hematoma evacuation for at least 12 hrs to decrease the risk of reaccumulation of the hematoma.
14
Q
Absolute and relative contraindications for endometrial ablation
A
15
Q
What is Androgen Insensitivity Syndrome?
A
Genetically 46 XY but have mutated receptors for androgen leading to poorly functioning receptors > therefore, androgen action is not carried out, causing failure to produce male genitalia
Generally develop phenotypically as females because they have no clinically apparent androgen exposure. Breast development occurs because testosterone is aromatized to estrogen. However, they have no internal female organs and they generally have a shortened vagina.
There is an increased risk of testicular cancer if the testes are not removed **
16
Q
What is Swyer Syndrome?
A
XY gonadal dysgenesis
The testes fail to develop properly and thus there is no testosterone present to drive development of male genitalia. Also, since the testes do not develop properly, there is no AMH and these patients will have a uterus and cervix
17
Q
What is a Latzko repair?
A
Surgery typically performed to repair a vesicovaginal fistula, best performed 6-12 weeks after the inciting surgery
Surgical technique: cannulate the vesicovaginal fistula with a lacrimal duct probe or pediatric Foley to help the surgeon pull the involved area of vagina toward the introitus to facilitate vaginal dissection. The vaginal epithelium is incised around the fistula. Vaginal epithelial flaps are then raised and removed in a circle with a diameter of 2-3 cm around the fistula tract. Two layers of 2-0 or 3-0 absorbable sutures are placed in a transverse interrupted fashion to close the defect without tension.
18
Q
Treatment of choice for endometriomas >5 cm in size
A
Surgical excision… allowing pregnancy rate to be >60%
19
Q
Endometriosis is a common cause of pelvic pain and can lead to infertility. The mechanism of infertility is not specifically known, but endometriosis can damage the fallopian tubes and cause unfavorable inflammatory environment in the pelvis that can hinder sperm function.
Removal of endometriomas has been found to increase fertility rate. What is the pregnancy rate following excision?
A
56-65%
20
Q
Fire Risk Score
A
21
Q
Most common case of rectovaginal fistula?
A
Birth trauma
22
Q
On HSG, the fallopian tubes appear dilated. What is the correct antibiotic choice for this procedure?
A
23
Q
When is a psoas hitch used?
A
When an iatrogenic ureteral injury is not able to be reimplanted into the bladder without tension
Ureter injuries that cannot be safely repaired with a ureteroneocystotomy because the repair would be placed under tension are good candidates for psoas hitch. The bladder is mobilized on the contralateral and ipsilateral side. A cystotomy is placed in the dome of the bladder. This hole is used to anchor the bladder to the psoas tendon and reimplant the ureter.
24
Q
When should the appendix be removed during gynecological surgery?
A
When mucinous carcinoma is diagnosed
25
Patient with **vesicovaginal fistula.** What is the BEST method to repair this fistula?
1. Excise vaginal epithelium and remove fistulous tract with a border of approximately 2 to 3 cm
2. Place multiple layers of absorbable sutures in an transverse interrupted fashion. The second layers are used to imbricate the tract.
26
24 yo G4P2012 Jehovah's Witness is undergoing emergent cesarean hysterectomy 2/2 hemorrhage. Refuses blood products. Despite receiving 2 L of LR (crystalloid), her BP is 60/40. What is the most appropriate transfusion to receive?
**Colloid** (volume expander) - provides increased osmolarity in the intravascular spaces, providing oncotic pressures in the vasculature
Types: albumin, dextran, gelatin, hydroxyethyl starches
27
Repair of bladder dome injuries during gyn procedures
28
How to repair a **full-thickness injury** to the small bowel?
**Double-layer closure** with suture lines **perpendicular to the long axis of the bowel** to avoid narrowing the bowellumen
29
Common Uterotonic Agents
30
During pelvic surgery, if you encounter major bleeding, which major vessel should be ligated to decrease blood flow to the pelvic viscera?
Hypogastric a/Internal iliac a. (which gives rise to the uterine and vaginal arteries)
31
You are removing a large 20-cm ovarian mass from a 23-yo nulligravid women to preserve her fertility. During open approach with midline incision, the **L ureter becomes compromised** **at the level of the pelvic brim**. Which of the following methods should be utilized for the repair?
Ureteroureterostomy
Preferred method to repair a simple transection at the level of the pelvic brim
32
What is the Boari flap?
Includes creating a bladder flap, mobilizing the bladder flap, and transfixing the psoas tendon and implanting the ureter into the flap. This technique is used to repair injuries to the mid-ureter.
33
Why does a radical hyst carry the highest risk of VVF?
because the upper 1/3 of the vagina is removed, incidence 1/81 cases
34
Which type of hysterectomy carries the highest risk of ureter injury?
Laparoscopic-assisted vaginal hysterectomy
35
What method should be employed when repairing a ureter that is injured at the time of a salpingo-oophorectomy?
Ureteroureterostomy repair
During a salpingo-oophorectomy, the ureter is at risk of being injured when the IP ligament (ovarian vessel) is coagulated and transected. The repair should be tension free, and at this level, an end-to-end ureteroureterostomy is recommended. The repair is carried out over a stent. Mobilization of the ureter distally should take place so additional length can be obtained. Following mobilization at both the proximal and distal ends on opposing sides, the surgeon spatulates the ureter. Interuppted sutures (small-gauge) are used to repair the injury over the stent.
36
What diagnosis is MOST appropriate indication for appendectomy at time of her laparoscopic cystectomy?
Mucinous cystadenoma
Benign epithelial ovarian tumor. It is thicker-walled mucoid-containing tumor that is lined with a single layer of columnar cells. **Pseudomyxoma peritonei** occurs when a mucin-producing tumor of an appendiceal origin spreads to the ovary and implants through the abdomen.
37
How do NSAIDs work in regards to platelet function?
Decrease inflammation by non-selectively reversibly inhibiting both COX-1 and COX-2 enzymes.
Their effect on platelet function is mediated by COX-1 inhibition, thereby decreasing production of TXA2, which decreases platelet aggregation.
38
During a hysterectomy, where is the most common place to injure the ureter?
At the level of the cervix (uterine artery and occurs in 80% of ureter injuries
39
The most common locations of ureteral injury in pelvic surgery are: (5)
40
During a TLH, a ureter is transected during the colpotomy. How should this injury be repaired?
Ureteroneocystotomy with psoas hitch
When the ureter is injured at this level, it is best to re-implant it into the bladder.
41
A 40 yo presents for TLH, BSO, and cystoscopy. PCN allergic. Appropriate pre-op abx?
Clindamycin + gentamicin
42
If an ovarian tumor found in childhood or adolescence, it is most likely \_\_\_\_\_\_.
Germ cell tumor (AFP and LDH both elevated)
43
What day typically does fever present for surgical incision infection?
POD 5-7
44
Post Op fevers: cause
* POD 1-2: inflammatory response
* POD 4-7: pneumonia, UTI
* POD 5-7: surgical site infection, VTE, drugs
45
Hysteroscopic Distending Media
46
What nerves are most likely to be injured with a Pfannenstiel incision?
Iliohypogastric and ilioinguinal nerves
47
How does the **Maylard incision** differ from the **Pfannenstiel incision?**
The rectus sheath is not dissected away from the rectus abdominis muscle, and the bellies of the rectus abdominis muscle are transected.
Transection affords extensive access to the pelvis. However, it is technically more difficult because of its required isolation and ligation of the **inferior epigastric vessels.**
48
How long does it take for polyglactin 910 (Vicryl Repede) to full absorb?
Loses 50% of tensile strength in 30 days
Fully absorbed by 56-70 days
Degeneration occurs through hydrolysis and therefore causes less inflammatory reaction than surgical gut which degrades through proteolytic enzymatic
49
Examples of nonabsorbable suture
Silk, nylon, polypropylene (Prolene), and polybutester sutures
50
Fire triad
Oxidizer (i.e. oxygen, NO), fuel (i.e. drapes and alcohol) ignition source
51
Managing **septic abortion**
52
Suture, 25% of original tensile strength, absorption, common uses
Catgut
Chromic catgut
Monocryl
Vicryl
PDS
53
First choice regimens for TOA are:
54
How to identify the **inferior epigastric vessels?**
Branch of the external iliac vessel that is approximately 5 cm lateral to the pubic symphysis
The inferior epigastric vessels can typically be seen originating from the external iliac vessel immediately preceding the inguinal ligament
55
Treatments for endometriosis
56
What is the main arterial supply of the anterior abdominal wall?
* Superior epigastric
* Musculophrenic
* Deep circumflex iliac
* Inferior epigastrics
57
Which risk factor is most associated with postop SBO?
Perioperative transfusion
58
Hypoosmolar distension media
Isoosmolar distension media
Hypoosmolar: 3% sorbitol, 1.5% glycine
Isoosmolar: 5% mannitol, 2.2% glycine
59
Absolute and relative contraindications to MTX with ectopic
60
Maximum Recommended Doses of Local Anesthetics Commonly Used in Obstetrics
bupivacaine
lidocaine
ropivacaine
61
Managing Bowel Injuries in Gynecologic Surgery
Veress needle injury
Trocar injury \< 1 cm
Perforating trocar injury
Thermal injury with bipolar
Full-thickness injuries to the small bowel require a two-layer closure. The layer may be a continuous or interrupted 3-0 delayed absorbable suture that closes the mucosa and muscularis. The serosal layer is then closed with 3-0 interuppted silk sutures placed perpendicular to the long axis of the bowel.
62
Incidence of heterotopic pregnancy
1 in 30,000
63
The passage of the ureter under the UA is ___ cm lateral to the cervix in the tunnel of Wertheim.
1.5 cm
64
How to reduce vascular injury during trochar placement?
1. Position patient flat or in supine position
2. Avoid Trendelenburg position
3. Confirm complete paralysis of patient with anesthesiologist
4. Angle Veress needle toward the hollow of the pelvis at a 45 degree angle
65
What is the initial first-line treatment for hemorrhage after a D&C?
**FIRST,** examine the cervix for lacerations... if none \>\> **uterine massage**
66
Plan of action after perforation of uterus during suction D&C
A sharp entry (using suction curettage or a metal curettage instrument) requires **laparoscopy** to assess for damage to the bowel, bladder, and vasculature.
If entry occurs without suction, it is possible to perform hysteroscopy to assess extent of damage.
Following diagnosis and assessment for immediate damage, the procedure may be completed during ultrasound guidance if necessary, but should be done only after a more serious injury has been identified and ruled out.
67
Is there a superior method for laparoscopic entry?
(Open Hasson, Single-incision, Veress needle, Veress needle at Palmer's point)
No.
A Cochrane review did NOT show a statistical difference in any of the main abdominal techniques for entry. The authors did note a lack of large randomized trials and insufficient evidence to show whether there were differences between groups in the rate of failed entry, vascular injury, or visceral injury, or in other major complications with the use of an open-entry technique in comparison to a closed-entry technique.
68
Which sonographic finding is consistent with the uterine anomaly withe BEST reproductive prognosis?
**Uterine didelphys = failed fusion of the Mullerian ducts results in 2 separate uterine horns with its own cavities and cervix**
Two completely separate divergent uterine horns with a deep fundal cleft between the 2 hemiuteri and a widened angle between 2 endometrial cavities
Pregnancy often develop normally in 1 of the 2 horns.
69
When performing laparoscopy, what comorbid condition places the patient at HIGHEST risk of morbidity or mortality?
COPD
Nonreversible. When performing laparoscopy, CO2 is used to insufflate the peritoneum and is rapidly absorbed and enters the bloodstream. When this occurs, the patient becomes more acidotic due to hypercarbia. For most patients without underlying respiratory disease, this can be managed by increasing the RR. However, for patients with severe COPD, the existing damage to the lung parenchyma inhibits CO2 exchange out of the lungs, increasing the risk of complications during the surgery.
70
Treatment of choice for endometriomas \> 5 cm in size
Excision of cyst wall
71
How does laparoscopic insufflation contribute to perioperative hypotension?
Decreases venous return due to increased intra-abdominal pressure.
72
Which electrolyte disorder worsens ileus?
Hypokalemia
73
What is gestational trophoblastic neoplasia?
How to diagnose?
group of neoplasia that occurs after a pregnancy event
After the evacuation of a molar pregnancy, **GTN can occur about 20% of the time, with 75% of those cases being an invasive mole and 25% being choriocarcinoma.**
**If hCG levels rise greater than 10% over three measurements 2 weeks apart, or if levels remain within 10% of the previous result for four measurements 3 weeks apart**
74
What nerve roots contribute to the femoral nerve?
L2-4
75
What is the best approach for pelvic organ prolapse in women who are not candidates for extensive surgery and who do not desire future vaginal intercourse?
Colpocleisis.
76
SIRS criteria
77
What is the primary mechanism of spread of ovarian epithelial tumors?
**Exfoliation**, through which malignant cells are released into the peritoneal cavity when the ovarian capsule is ruptured.
These cells are carried by the circulating peritoneal fluid throughout the abdomen and implant on the surface of abdominal organs, typically without invasion into the visceral organs
78
Rome IV Criteria for IBS
* Patient will be a woman
* With a history of constipation alternating with diarrhea
* Complaining of abdominal discomfort which **is relieved with bowel movements**
* Diagnosis is made by Rome criteria
* Treatment is symptomatic - dietary management and drugs
79
What is the characteristic histologic appearance of choriocarcinoma?
Sheets of anaplastic cytotrophoblasts and syncytiotrophoblasts without chorionic villi.
80
At what age would performing an oophorectomy increase overall mortality risk?
Below the age of 45
81
Why is cervical conization necessary for atypical glandular cells?
Skip lesions may be present.
82
What is the preferred anticoagulation agent after a deep vein thrombosis for a patient who is not pregnant but has severe renal dysfunction?
Warfarin
83
Types of Pelvic Organ Prolapse Surgery
84
Where does the inferior epigastric artery arise from?
External iliac a.
85
In the absence of prosthetic material, within how many days after the procedure can an infection occurring at or near the surgical incision be classified as a surgical site infection?
30
86
Between what layers of the abdominal wall do the inferior epigastric vessels run?
The posterior rectus sheath and the rectus abdominis muscles.
87
What is the best initial treatment intervention if there is uncertainty about the integrity of a ureter after suspected injury?
Ureteral stent.
88
Addition of **metronidazole** or **clindamycin** to the treatment regimen of a tubo-ovarian abscess improves coverage of what type of organisms compared to **doxycycline** alone?
Anaerobes.
89
Anticoagulation management
90
A patient with bipolar disorder on lithium is about to undergo a hysterectomy. By what mechanism does lithium increase the effect of neuromuscular blockers?
decreases the release of neurotransmitters and may prolong the effects of neuromuscular blockers
inhibits the activation of potassium channels, therefore preventing the release of neurotransmitters.
91
During a laparoscopic procedure, the anesthesiologist informs you the patient is suddenly hypotensive, and on auscultation, they can hear “mill-wheel murmur.” What is the most likely diagnosis?
Intra-cardiac air embolus.
92
Various forms of uterine anomalies can affect women. Several are asymptomatic and incidentally diagnosed. The hysteroscopic appearance above can be associated with two types of anomalies: **bicornuate uterus** and **complete uterine septum**. Both may clinically present with infertility, recurrent pregnancy loss, preterm rupture of membranes, and fetal malpresentation.
While a uterine septum can be easily resected via operative hysteroscopy using cold scissors or electrocautery, corrective surgery for bicornuate uterus, if indicated, is a more morbid procedure which is performed via laparotomy.
Differentiation between the two is performed by imaging modalities that provide a coronal reconstructive view of the uterus such as **magnetic resonance imaging and three-dimensional ultrasound**. Hence, before any further surgical intervention in the clinical vignette above, it would be appropriate to perform intraoperative three-dimensional ultrasonography.
93
A 65-year-old woman is undergoing a total vaginal hysterectomy for stage 1 uterine prolapse. Which of these structures is most likely transected first during the procedure?
During a vaginal hysterectomy in a patient with mild to moderate uterine prolapse, the **uterosacral ligaments** are typically transected and ligated first. This approach is known as the **Heaney technique.**
94
What is the preferred antibiotic regimen for pelvic inflammatory disease in women with severe penicillin allergy?
Clindamycin and Gentamicin
95
What clinical element is suggestive of a monomicrobial etiology for necrotizing fasciitis?
Absence of gas in soft tissue.
96
Which hereditary cancer syndromes have been associated with increased risk of leiomyosarcoma?
Hereditary retinoblastoma syndrome, Li-Fraumeni syndrome, tuberous sclerosis, and neurofibromatosis type 1, among others.
97
Treatment for lichen planus if resistant to topical steroids?
Tacrolimus
98
What is the most common type of malignant germ cell tumor in the pediatric population?
Dysgerminoma.
99
What is the most common postprocedural complication of uterine artery embolization?
Pelvic pain.
100
What drug class is ulipristal?
Selective progesterone receptor modulator.
101
What type of energy is used with the Harmonic device?
High-frequency mechanical vibration.
102
A 62-year-old woman presents with the complaint of vulvar itching and pain with intercourse. On exam, you note a loss of portions of the labia minora as well as thin, white, wrinkled skin on the vulva. What is the most likely diagnosis given her history and physical exam?
Lichen Sclerosis
103
How often should a pessary be removed and replaced?
Every 3-4 months.
104
You suspect a bowel injury. Which diagnostic tests is the most useful to confirm your suspected diagnosis?
CT
105
Which of the following findings is required for the diagnosis of pelvic inflammatory disease?
1. Fever
2. Infection with Neisseria gonorrhoeae or Chlamydia trachomatis
3. Mucopurulent cervical dischargeYour Answer
4. Pelvic pain
4. Pelvic pain
106
Adnexal Mass (Differential Diagnosis)
107
What CA 125 level in a premenopausal patient would prompt a referral to gynecology oncology?
Greater than 200 U/mL.
108
Recommended antibiotics prophylaxis pre-procedure
109
Pseudogestational sac vs. gestational sac
110
Definition of primary amenorrhea
Failure of menses to occur by age 15 despite normal growth of secondary sexual characteristics
Failure of menses to occur by age 13 in the absence of secondary sexual characteristics
111
What is the histologic type of ovarian cancer mostly associated with BRCA1 and BRCA2 mutations?
High grade serous or endometrioid
112
When should a patient discontinue combined oral contraceptive pills prior to surgery?
At least 4 weeks prior
113
How are women with Lynch syndrome screened for endometrial cancer?
EMB every 1-2 years starting 30-35 yo
114
Distending Media for Hysteroscopy
115
What type of distension media does use of monopolar electrocautery require?
Electrolyte-poor media
116
What is ectropion?
Eversion of the endocervix exposing the columnar epithelium to the vaginal milieu.
117
First line treatment for TSS?
Majority of TSS caused by what organism?
Clindamycin and Vancomycin
methicillin-susceptible S. aureus
118
What is the inheritance pattern for 21-hydroxylase deficiency?
Autosomal Recessive
119
A 35-year-old woman presents to your office for consultation. She has a history positive for a complete hydatidiform mole that was evacuated four months ago with dilation and curettage. Post evacuation, her serum human chorionic gonadotropin levels (hCG) have been plateaued for more than four weeks. Which of the following is the best next step in management?
Prognostic scoring
120
What is the most commonly used chemotherapeutic regimen for granulosa cell tumors?
Bleomycin, etoposide, and cisplatin (BEP protocol).
121
Steps of a vaginal hysterectomy
The first steps for removing the uterus can occur in the typical fashion, using a bipolar sealing and cutting device or conventional clamps and sutures for ligation of the blood vessels.
The vesicovaginal space is dissected and the cul-de-sac opened. The uterosacral ligaments and uterine artery must then be coagulated and cut. Next, the anterior peritoneum is opened, and the uterus is rotated posteriorly to visualize the fallopian tubes.
If posterior rotation fails, anterior rotation of the uterus can be performed instead. Once the fallopian tubes are well visualized, the goal is to coagulate and cut the vasculature while leaving the tube attached to the uterus.
To perform this task, the tubo-ovarian ligament and mesosalpinx are coagulated with a bipolar sealing device, electrosurgical knife, or sutures.
The utero-ovarian and round ligaments are cut in a similar fashion. The uterus and fallopian tubes are then removed together.
122
What neurologic deficits may be encountered if a patient’s arm is inappropriately positioned during surgery and there is compression at the medial epicondyle?
Loss of sensation of the fourth and fifth digits.
123
Mechanism of action of Letrozole
124
First line treatment for vaginal cuff cellulitis
Treatment is PO OUTPATIENT
Amoxicillin-clavulanate 875/125 PO BID
Ciprofloxacin 500 mg po bid with metronidazole 500 mg po bid,
TMP-SMX DS po bid with metronidazole 500 mg po bid
125
Mechanism of action of **cefazolin**
inactivation of penicillin-binding proteins to prevent peptidoglycan synthesis and subsequent cell wall synthesis
126
Mechanism of action of **tetracyclines and aminoglycosides**
binding to the 30S ribosomal subunit
127
Treatment of ovarian germ cell tumors in adult patients
128
Management of vulvar abscesses
129
Uterine prolapse stages
130
What structure provides primary support to the pelvic organs?
Levator ani muscle complex (pubococcygeus, puborectalis, and iliococcygeus muscles).
131
The Müllerian duct develops into what structures in a woman?
Uterus, fallopian tubes, cervix, and upper vagina.
132
What is the second most common site of ureteral injury during gynecologic surgery?
Infundibulopelvic ligament.
133
Which surgical route for hysterectomy has the lowest rate of vaginal cuff dehiscence?
Vaginal hysterectomy
134
For a hysterectomy without ovarian pathology, until what age is ovarian preservation recommended?
Age 65
135
What is the preferred imaging study of choice for the diagnosis of appendicitis in a nonpregnant patient?
CT
136
Treatment and surveillance for early stage endometrial cancer
TAH BSO is the mainstay in treatment of early-stage endometrial cancer.
Pelvic lymphadenectomy is performed in the setting of myometrial invasion of more than half of high-grade tumors, lymphovascular invasion, or large intracavitary masses. P
ost-treatment surveillance aims to detect recurrent disease early enough to allow for intervention. History and physical examination are the mainstay in post-treatment follow-up. Examination consists of **speculum and bimanual pelvic exams every three to six months for two years.** This is followed by examination every six months or annually based on the risk of recurrent disease.
137
A 26-year-old G0 woman presents to your office for routine gynecologic care. On physical exam, you note multiple hamartomas on her skin and in the lining of her mouth and nose. She was adopted as a child but thinks her biological mother was diagnosed with some form of cancer when she was 30. She is concerned she is at risk of a hereditary cancer syndrome. Based on her physical exam, for which hereditary cancer syndrome are you most suspicious?
138
Course of the ureter into the pelvis
The ureter enters the pelvis and crosses anterior to the bifurcation of the common iliac artery. From there, it courses medial to the ovarian vessels and descends into the pelvis in the pelvic sidewall peritoneum lateral to the internal iliac artery. At the level of the uterine isthmus, the ureter runs posterior to the uterine artery and runs anteromedially until it enters the bladder.
139
What is the preferred repair method for complete transection of the ureter within 6 cm of the bladder?
Reimplantation into the bladder (ureteroneocystostomy).
140
Endometriosis is associated with an increased risk of what ovarian malignancies?
Clear cell and endometrioid adenocarcinoma.
141
A 56-year-old postmenopausal woman presents to your office for shortness of breath. Physical exam findings are significant for pleural effusions. Upon your workup, you note a cancer antigen 125 of 263 U/ml, abdominal ascites, and ovarian masses illustrated in the picture above. No evidence of carcinomatosis or other abnormalities were observed on imaging. What is the best approach to treat her ascites?
Salpingo-oophorectomy
142
Above what level is CA 125 considered elevated in postmenopausal women?
35 U/mL
143
Uncomplicated stress urinary incontinence (6 steps)
There are six minimum steps of evaluation for this condition: history, urinalysis, physical examination, demonstration of stress incontinence, assessment of urethral mobility, and measurement of postvoid residual volume.
If the evaluation clearly points to uncomplicated stress urinary incontinence, a midurethral sling is a popular and effective surgical treatment.
144
What are the risk factors of underlying malignancy in dermoid cysts?
Age over 45 years, tumor diameter greater than 10 cm, rapid growth, and specific findings on imaging.
145
What is the classic histologic finding in the adult-onset granulosa cell tumors?
Coffee bean nuclei and Call-Exner bodies.
146
What are the two primary patterns of spread of cervical cancer?
Direct extension or lymphatic spread.
147
How long does it take for serum human chorionic gonadotropin values to return to normal after a completed abortion?
2-6 weeks
148
Which medication is used to prevent hemorrhagic cystitis caused by alkylating agents?
Mesna
149
What is the MOA of TXA?
antifibrinolytic drug that reversibly blocks lysine binding on plasminogen to inhibit the fibrinolytic cascade.
150
What triad suggests ilioinguinal nerve entrapment?
Pain radiating from the incision site to the labia, paresthesia of the painful area, and pain relief after anesthetic infiltration.
151
Le Fort colpocleisis vs. total colpocleisis
Le Fort: obliterative procedure that can be used to treat pelvic organ prolapse. **Obliterative procedures are easier and faster than reconstructive procedures.** As such, they are better tolerated by **older women.** The caveat is that vaginal intercourse is **no longer possible after obliteratio**n.
Cervical cancer screening and endometrial sampling are not possible after obliteration, so an appropriate evaluation should be performed preoperatively.
Total colpocleisis results in an absence of drainage tracts, so it is ideal in someone with a previous hysterectomy.
152
Which ligaments help to support the upper vagina?
Uterosacral and cardinal ligaments
153
Which hysterectomy approach is associated with the highest risk of vesicovaginal fistula formation?
Laparoscopic
154
What types of bowel injury do not typically necessitate repair?
Serosal abrasions and Veress needle injuries.
155
Endometrial carcinomas histological types
156
MTP
Massive transfusion is defined as the replacement of 1 blood volume, or approximately 10 units of packed red blood cells (PRBCs), within 24 hours.
* Administer platelets if count is \< 100,000/microliter
* Administer FFP for INR \> 1.5
* Administer cryoprecipitate if fibrinogen level is \< 150–200 mg/dL
157
How often are endometriomas found bilaterally?
1/3 of the time
158
How many days prior to surgery should antiplatelet agents be stopped?
Aspirin should be stopped 7–10 days prior to surgery, and clopidogrel should be stopped 5–7 days prior to surgery.
159
Which three factors are used for histologic grading of sarcomas?
Tumor differentiation, mitotic index, and percent of tumor necrosis.
