PROLOG: Gynecology Flashcards
Ultrasound findings concerning for ovarian cancer (5)
What is the initial first-line treatment for hemorrhage after a D&C?
Uterine massage + uterotonics
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?
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.
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 ___%.
5-15%
30-40%
0.9%
Ovarian Tumors and their associated positive tumor markers
Dysgerminoma
Endodermal Sinus
Granulosa Cell
Choriocarcinoma
Immature Teratoma
Embryonal Carcinoma
Epithelial Ovarian cancers
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?
Saline infusion sonogram (SIS)
Mullerian Anomalies
Leiomyoma: Hypoechoic, well-circumscribed round masses with posterior acoustic shadowing
Early Pregnancy Loss: Diagnosis
MOA: Mifepristone
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.
Most effective medical regimen for EPL
Mifepristone + misoprostol
Mifepristone 200 mg PO 24 hr then 24-48 h later > misoprostol 800 mcg buccally / vaginally
Most common surgical procedure performed for treatment of stress urinary incontinence
Midurethral sling
How to manage an expanding vulvar hematoma?
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.
Absolute and relative contraindications for endometrial ablation
What is Androgen Insensitivity Syndrome?
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 **
What is Swyer Syndrome?
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
What is a Latzko repair?
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.
Treatment of choice for endometriomas >5 cm in size
Surgical excision… allowing pregnancy rate to be >60%
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?
56-65%
Fire Risk Score
Most common case of rectovaginal fistula?
Birth trauma
On HSG, the fallopian tubes appear dilated. What is the correct antibiotic choice for this procedure?
When is a psoas hitch used?
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.
When should the appendix be removed during gynecological surgery?
When mucinous carcinoma is diagnosed
Patient with vesicovaginal fistula. What is the BEST method to repair this fistula?
- Excise vaginal epithelium and remove fistulous tract with a border of approximately 2 to 3 cm
- Place multiple layers of absorbable sutures in an transverse interrupted fashion. The second layers are used to imbricate the tract.
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
Repair of bladder dome injuries during gyn procedures
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
Common Uterotonic Agents
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)
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
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.
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
Which type of hysterectomy carries the highest risk of ureter injury?
Laparoscopic-assisted vaginal hysterectomy
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.
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.
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.
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
The most common locations of ureteral injury in pelvic surgery are: (5)
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.
A 40 yo presents for TLH, BSO, and cystoscopy. PCN allergic. Appropriate pre-op abx?
Clindamycin + gentamicin
If an ovarian tumor found in childhood or adolescence, it is most likely ______.
Germ cell tumor (AFP and LDH both elevated)
What day typically does fever present for surgical incision infection?
POD 5-7
Post Op fevers: cause
- POD 1-2: inflammatory response
- POD 4-7: pneumonia, UTI
- POD 5-7: surgical site infection, VTE, drugs
Hysteroscopic Distending Media
What nerves are most likely to be injured with a Pfannenstiel incision?
Iliohypogastric and ilioinguinal nerves
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.
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
Examples of nonabsorbable suture
Silk, nylon, polypropylene (Prolene), and polybutester sutures
Fire triad
Oxidizer (i.e. oxygen, NO), fuel (i.e. drapes and alcohol) ignition source
Managing septic abortion
Suture, 25% of original tensile strength, absorption, common uses
Catgut
Chromic catgut
Monocryl
Vicryl
PDS
First choice regimens for TOA are:
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
Treatments for endometriosis
What is the main arterial supply of the anterior abdominal wall?
- Superior epigastric
- Musculophrenic
- Deep circumflex iliac
- Inferior epigastrics
Which risk factor is most associated with postop SBO?
Perioperative transfusion
Hypoosmolar distension media
Isoosmolar distension media
Hypoosmolar: 3% sorbitol, 1.5% glycine
Isoosmolar: 5% mannitol, 2.2% glycine
Absolute and relative contraindications to MTX with ectopic
Maximum Recommended Doses of Local Anesthetics Commonly Used in Obstetrics
bupivacaine
lidocaine
ropivacaine
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.
Incidence of heterotopic pregnancy
1 in 30,000
The passage of the ureter under the UA is ___ cm lateral to the cervix in the tunnel of Wertheim.
1.5 cm
Which electrolyte disorder worsens ileus?
Hypokalemia
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
SIRS criteria
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
Types of Pelvic Organ Prolapse Surgery
Anticoagulation management
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.
Treatment for lichen planus if resistant to topical steroids?
Tacrolimus
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
Which of the following findings is required for the diagnosis of pelvic inflammatory disease?
- Fever
- Infection with Neisseria gonorrhoeae or Chlamydia trachomatis
- Mucopurulent cervical dischargeYour Answer
- Pelvic pain
- Pelvic pain
Adnexal Mass (Differential Diagnosis)
Recommended antibiotics prophylaxis pre-procedure
Pseudogestational sac vs. gestational sac
Distending Media for Hysteroscopy
What is the inheritance pattern for 21-hydroxylase deficiency?
Autosomal Recessive
Mechanism of action of Letrozole
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
Treatment of ovarian germ cell tumors in adult patients
Management of vulvar abscesses
Uterine prolapse stages
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?
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.
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
Endometrial carcinomas histological types
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
Which three factors are used for histologic grading of sarcomas?
Tumor differentiation, mitotic index, and percent of tumor necrosis.
