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RCSI NB OG Flashcards

1
Q 
Preterm Labour (PTL) 
def
incidence
A

before 37 weeks of gestation

11% of all live births

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2
Q

Labour prior to 24 weeks =

A

threatened miscarriage

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3
Q

PTL Causes

A

1/3 spontaneous PPROM
1/3 iatrogenic
1/3 idiopathic

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4
Q

Iatrogenic PTL Causes

A
  • Preeclampsia
  • IUGR
  • Maternal disease necessitating delivery
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5
Q

Spontaneous Preterm Delivery Causes

A
  • PTL
  • PPROM
  • Cervical incompetence
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6
Q

PTL risk factors

Non-pregnancy related

A
  • Low socio-economic group
  • Extremes of age
  • Poor nutritional status
  • Smoking
  • Drug abuse
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7
Q

PTL risk factors

Pregnancy related

A
  • Multiple pregnancy
  • PPROM
  • Uterine anomalies
  • History of preterm delivery in prior pregnancy
  • Placenta praevia
  • Placental abruption
  • Polyhydramnios
  • Medical complications of pregnancy eg PET
  • Intrauterine infection
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8
Q

Predict Preterm Delivery with two tests

A

Fetal Fibronectin

Transvaginal ultrasound

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9
Q

Tell me about Fetal Fibronectin/ Partosure

A
  • Glue-like protein binding the fetal membranes
  • Cervicovaginal swab at 23 and 35 weeks gestation should be negative
  • Positive swab - increased risk preterm delivery
  • Good negative predictive value <1% chance of delivery within a week – high specificity
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10
Q

Tell me about Transvaginal ultrasound

A 
Short cervix (<25mm) predicts 75% cases preterm delivery
Shorter the cervix = higher the chance of preterm delivery
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11
Q

Preterm Delivery Prevention

A

No proven preventative strategies

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12
Q

Progesterone for Prevention of Preterm Birth

A

Weekly IM injections of 17α-hydroxyprogesteone caproate
Reduced incidence of preterm delivery by 1/3 in patients with prior preterm delivery
NEJM

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13
Q

Preterm Labour – Role of Antibiotics

A

no benefit when membranes are still intact

ONLY FOR PPROM

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14
Q

GBS, listeria, mycoplasma, bacteroides, ureaplasma –> 15 - 20% of PTL

Tx GBS prophylaxis

A

3g benzylpenicillin IV

THEN 1.8g 6 hourly (clindamycin if penicillin allergic)

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15
Q

Cervical Cerclage

A

For high-risk cases, short cervix on transvaginal U/S

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16
Q

Preterm Delivery – Prevention

prophylactic vaginal progesterone or prophylactic cervical cerclage to women:

A
  • with a history of spontaneous preterm birth or mid trimester loss between 16+0 and 34+0 weeks of pregnancy and
  • in whom a transvaginal ultrasound scan has been carried out between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of less than 25 mm.
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17
Q

Preterm Delivery – Prevention

prophylactic vaginal progesterone to women

A

with no history of spontaneous preterm birth or mid trimester loss in whom a transvaginal ultrasound scan has been carried out between 16+0and 24+0 weeks of pregnancy that reveals a cervical length of less than 25 mm.

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18
Q

Preterm Delivery – Prevention

prophylactic cervical cerclage for women

A

transvaginal ultrasound scan between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of less than 25 mm
Hx P-PROM
LLETZ

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19
Q

Preterm Labour Dx

A
  • Regular contractions
  • Cervical change
  • Cervical dilatation
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20
Q

Preterm Labour – Management

A
  1. Administer antenatal corticosteroids
    Dexamethasone 6mg 12 hourly x 4 doses
    or
    Betamethasone 12mg IM 24hrly x 2 doses
  2. Tocolysis
  3. Transfer to tertiary level facility with NICU
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21
Q

Antenatal Corticosteroids

A

24 and 36 weeks
Reduction in Respiratory Distress Syndrome, neonatal mortality, Intraventricular Haemorrhage, Necrotising Enterocolitis and PDA

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22
Q

Commonly used tocolytics:

A

Atosiban: oxytocin receptor antagonist
Nifedipine: calcium channel blocker
Ritodrine or Terbutaline: beta adrenergic agonist
Magnesium Sulphate: competitive antagonist to calcium
Indomethacin: interferes with prostaglandin synthesis

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23
Q

Preterm Delivery Neonatal Complications

A
  • Respiratory distress syndrome (RDS)
  • Necrotising enterocolitis (NEC)
  • Intraventricular haemorrhage (IVH)
  • Periventricular leukomalacia (PVL)
  • Sepsis
  • PDA
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24
Q

PPROM

A

Preterm Premature Rupture of the Membranes
before 37 weeks gestation
1% to 3% of all pregnancies

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25
Q

Premature ROM

A

rupture of the chorioamniotic membranes prior to the onset of labour, and may occur at term

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26
Q

Prolonged ROM

A

ROM > 24hrs

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27
Q

PPROM Dx

A

Hx gush of fluid, constantly wet
Physical Exam pooling of fluid in the posterior vaginal fornix
Amnisure – for placental alpha-microglobulin 1 in cervicovaginal fluid. High sensitivity and specificity.
Ferning - broad fern pattern on microscopy vs narrow fern pattern of amniotic fluid
Vaginal swab pH - Nitrazine sticks turn blue in presence of amniotic fluid
Cervico-vaginal fetal fibronectin
Intraamniotic instillation of indigo carmine dye
Ultrasound

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28
Q

PPROM causes

A
  • Spontaneous / Idiopathic (most cases)
  • Infection: Chlamydia, GBS, Bacteroides
  • Smoking
  • Placental abruption
  • PPROM in prior pregnancy
  • Incompetent Cervix
  • Multiple Pregnancy (twins / triplets etc)
  • Polyhydramnios
  • Iatrogenic (after amniocentesis)
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29
Q

PPROM Risks

A 
Risk of infection 
Intrauterine infection 
Placental abruption 
Cord compression 
Fetal demise (1% - 2% of PPROM cases)
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30
Q

PPROM Surveillance

A 
•	Maternal signs of infection
•	Fetal signs of infection
•	Serum markers of infection
•	Ultrasound markers of fetal compromise
–	Altered biophysical profile (BPP)
•	CTG abnormalities
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31
Q

Signs of maternal infection

A
  • Pyrexia
  • Tachycardia
  • Uterine tenderness
  • Preterm labour
  • Foul smelling vaginal fluid
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32
Q

Signs of fetal infection

A 
•	Fetal tachycardia
•	Non-reactivity / reduced variability on CTG / variable decelerations
•	Alteration in biophysical profile
–	Loss of breathing movements
–	Decrease in gross body movements
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33
Q

Amniotic fluid markers of infection

A
  • Amniotic fluid glucose is low
  • Amniotic fluid white cell count is high
  • Amniotic fluid Gram stain / culture are positive
  • Amniotic fluid C-reactive protein > 20 mg/l
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34
Q

Mid trimester PPROM(16-25 wks)

A

Pulmonary hypoplasia less than 26 weeks gestation
overall survival is 50-75%
50% deliver within a week, 20% continue for over a month after occurrence of PPROM

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35
Q

When PPROM occurs, WHAT significantly improved perinatal outcome

A

10 day course of Erythromycin 250mg QDS

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36
Q

All cases of PPROM should be delivered by

A

37 weeks

OR immediately if fetal compromise or infection, even without evidence of fetal lung maturity

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37
Q

Outpatient management of PPROM

A
  • patient clinically very well for the first few days after PROM (no pain, no bleeding, no signs of infection)
  • no major co-morbidities in the pregnancy
  • corticosteroids are complete
  • lives in close proximity to the hospital
  • good support at home
  • the patient at home four hourly temperature monitoring
  • the hospital has an appropriate day care unit where the patient can come in regularly for assessment of fetal and maternal wellbeing
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38
Q

Threatened Miscarriage -

A

Vaginal bleeding associated with a viable intrauterine pregnancy up to 24 weeks gestation

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39
Q

Antepartum Haemorrhage

A

Vaginal bleeding from 24 weeks until the onset of labour

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40
Q

Intrapartum Haemorrhage

A

Vaginal bleeding from the onset of labour until the end of the 2nd stage of labour

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41
Q

Postpartum Haemorrhage

A

Vaginal bleeding from the third stage of labour until the end of the puerperium (6 weeks postpartum)

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42
Q

APH causes

A

Placenta Praevia 30%
Placental Abrupti 20%
Local Causes 5%
Unclassified 45%

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43
Q

Placenta praevia
def
Incidence

A

partially or wholly situated in the lower uterine segment
1 in 20 at 24 weeks
1 in 200 at 40 weeks
Nulliparous 0.2% Multiparous 0.5%

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44
Q

Placenta praevia

what do you want to know

A

ant or post

ant –> accreta/percreta if Hx C-S

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45
Q

Placenta praevia
grade I
Minor

A

If the leading edge of the placenta is within 2cm of the internal cervical os
(low lying placenta)

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46
Q

Placenta praevia
grade II
Minor

A

Reaches the internal os (marginal)

There is little if any difference between marginal and partial degree of placenta praevia

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47
Q

Placenta praevia
grade III
Major

A

Covers the os but asymmetrically situated

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48
Q

Placenta praevia
grade IV
Major

A

Covers the os, centrally located

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49
Q

Risk Factors for Placenta Praevia

A 
Prior Uterine Surgery
Caesarean Section (10x risk after 3 c-sections)
Curettage
Myomectomy
Surgical TOP (2x Risk after 2 TOPs)
Increased parity
Advanced maternal age 9 x risk in >40 vs <20yrs
Multiple pregnancy
Smoking
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50
Q

P/C Placenta previa

A

Painless vaginal bleeding which can be unprovoked or occurs post coitus or following uterine contractions
First episode of haemorrhage usually not severe & typically painless
Often asymptomatic: Incidental diagnosis seen on routine obstetric ultrasound

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51
Q

Physical exam Placenta previa

A
  1. Uterus soft and non-tender
  2. Fetal heart rate is usually normal
  3. Typically high presenting part or malpresentation, because head cannot descend into pelvis
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52
Q

Never do what in Placenta previa

A

VAGINAL EXAM

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53
Q

Dx Placenta previa

A

TVUS

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54
Q

risks of Placenta previa

maternal

A
  • Haemorrhage
  • Co-existent abruption
  • Placenta Accreta (15%)
  • Hysterectomy
  • Death
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55
Q

Risks of Placenta previa

fetal

A 
•	Preterm birth
•	IUGR 
–	Common in women with multiple bleeds. 
–	Overall rate 15% in praevia
•	Death
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56
Q

Placenta previa Immediate Management

A 
IV Line (14G x 2)
FBC/Coag/X-match 4 units
IV Fluids
O Negative blood 
Call for senior help (obstetric and anaesthesia) NICU
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57
Q

Subsequent management of placenta praevia:

Has bleeding stopped?
Was it mild bleeding?
Was it a life-threatening bleed?
Is fetal testing non-reassuring?
What is gestational age?
A

Immediate delivery OR

Expectant management

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58
Q

Immediate delivery for placenta previa if

A

severe haem
non reassuring CTG
34-36 wks +/- steroids

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59
Q

Expectant management of praevia

A

exceptional / stable circumstances in women who have never had significant vaginal bleeding and live close to the hospital with good immediate family supports

Aim for delivery at 37 weeks

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60
Q

Mode of delivery of praevia

A

Elective C-section + spinal/epidural

unless type 1 and formation of lower segment has resulted in vertex passing the edge of the placenta

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61
Q

Placenta Accreta
cause?

use MRI and/or colour doppler USS

A

chorionic villi in contact with myometrium (80% of cases)

primary deficiency of or secondary loss of decidual elements (decidua basalis)

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62
Q

Placenta Increta

A

chorionic villi invade into myometrium (15% of cases)

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63
Q

Placenta Percreta

A

chorionic villi invade into serosa or beyond (5% of cases)

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64
Q

abnormal placentation a/w

A

Hx prior c section
uterine instrumentation fibroid surgery
prior placenta praevia

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65
Q

patient with suspected placenta accreta should be fully counselled before CS about possibility of

A

caesarean hysterectomy massive intrapartum haemorrhage

blood transfusion

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66
Q

Placental Abruption
Incidence:
Recurrence risk in subsequent pregnancy:

A

Premature separation of normally sited placenta
1 in 150 deliveries
5 –15%

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67
Q

Abruption classification

A

Revealed haemorrhage vs Concealed haemorrhage

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68
Q

Risk factors for Placental Abruption

A 
Chronic hypertension / preeclampsia
Abdominal trauma
Cocaine use
Smoking
Prolonged PROM/chronic chorioamnionitis
High parity
Abruption in prior pregnancy
Maternal thrombophilia (factor V leiden etc)
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69
Q

Symptoms of Abruption

Clinical Signs of abruption:

A

Abdominal pain
Backache
+/- Vaginal bleeding

Faint or collapse = shock
Uterus Wood-like, Irritable
Fetal parts difficult to palpate and fetal heart may be inaudible

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70
Q

Diagnosis of abruption:

A

clinical

U/S to rule out placenta previa

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71
Q

Management of abruption:

A

IV Line: FBC, Group and x match 4 units, Coagulation screen
Continuous CTG
If baby is alive - emergency c section
If fetus already dead amniotomy & vaginal delivery

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72
Q

Complications of abruption:

A

Coagulopathy = decreased fibrinogen level, decreased platelets & raised fibrin degradation products
30%
DIC
Hypovolemia

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73
Q

Local Causes of APH

A

U/S r/o placenta praevia speculum examination r/o cervical cancer
cervical ectropion
cervicitis
foreign body
safe to take a cervical smear in pregnancy

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74
Q

Vasa Praevia

A

vessels of the umbilical cord run in the fetal membranes and cross the internal cervical os = velamentous insertion of the cord
Rare: 0.1%
P/C intrapartum haemorrhage at SROM or AROM
rapid fetal haemorrhage/ bradycardia/ death
emergency caesarean section

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75
Q

All rhesus negative women should receive anti-D injection

A

Routine Antenatal prophylaxis
Following any sensitising events (PVB/ Invasive fetal testing (Amniocentesis or CVS)/ post trauma/ cervical cerclage/management of a miscarriage or ectopic pregnancy)
Post partum if the infant is confirmed Rh Positive

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76
Q

Kleihauer test

A

estimates the volume of fetomaternal haemorrhage

calculate appropriate dose of anti D

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77
Q

5 Rh antigens

A

D; C; c; E; e.

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78
Q

Rh neg mom and first Rh pos pregnancy

A

Fetal Rh Antigen

–> Anti- D IgM, which cannot cross the placenta to cause fetal haemolysis

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79
Q

Rh Tx

A

in utero blood transfusion
delivery
>34 weeks followed by neonatal exchange transfusion or Neonatal top- up transfusion
continuous monitoring
Cord blood should be sent for Direct antiglobulin test, heamoglobin and bilirubin levels
Neonatal observation for jaundice and /or anaemia
Regular feeds

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80
Q

rh monitoring

A

Maternal Anti D titres
Every 4 weeks until 28weeks gestation
Every 2 weeks until birth

Fetal Biometry and Biophysical Profile
Fetal Middle Cerebral Artery peak systolic velocities (MCA-PSV) weekly

Referral to fetal medicine
Anti-D level >4 IU/ml
MCA PSV >1.5 MoM (Multiples of Mean)
Hydrops

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81
Q

Hypertension in pregnancy

A

BP of at least 140mmHg systolic or 90mmHg diastolic on at least 2 occasions 6 hours apart that occurs after 20 weeks’ gestation

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82
Q

Proteinuria

A

Excretion of ≥ 300mg of protein in 24h

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83
Q

Pregnancy induced hypertension

A

Hypertension that develops as a consequence of the pregnancy and that regresses in postpartum

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84
Q

Pregnancy aggravated hypertension

A

Underlying hypertension worsened by pregnancy

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85
Q

PREECLAMPSIA or PET (Proteinuric pregnancy induced hypertension)

A
  • hypertension during pregnancy
  • Proteinuria
  • +/- pathological oedema
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86
Q

ECLAMPSIA

A

Seizures + pre-eclampsia

25% seizures post-partum

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87
Q

Pre-eclampsia 2 theories

A

Vascular: reduction in placental blood flow secondary to abnormal placentation or maternal microvascular disease
poorly perfused placenta releases circulating factor’s target maternal vascular endothelium
Immune: Maternal alloimmune reaction triggered by rejection of the fetal allograft

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88
Q

vascular pre-eclampsia theory

A

trophoblast cells migrate into the uterine wall and replace the endothelium of spiral arteries –> low-resistance arteriolar system –>
placental ischaemia
OR
excessive size = hyperplacentosis

89
Q

The Immune Theory Of PET

A

Sperm exposure causes mucosal alloimmunisation –> classic inflammatory response

90
Q

Systemic Inflammatory Response in PET BECAUSE OF

A

endothelial activation

91
Q

Risk Factors For Pre-eclampsia

A 
Nulliparity
 Extremes of maternal age
Pre-eclampsia in a previous pregnancy
25% risk if onset < 34 weeks
50% risk if onset <28 weeks 
Chronic hypertension or renal disease
Obesity
Insulin resistance / diabetes
Thrombophilia
Family Hx
Multiple pregnancy
92
Q

Cardio effects of PET

A

Increased peripheral resistance (raised BP)

Increased vascular permeability & reduced maternal plasma volume.

93
Q

Resp effects of PET

A

pulm oedema

94
Q

Renal effects of PET

A

Glomerular damage leads to proteinuria, hypoproteinaemia, reduced oncotic pressure.

95
Q

coag effects of PET

A

Hypercoagulability

DIC

96
Q

liver effects of PET

A

HELLP syndrome

Hepatic rupture.

97
Q

CNS effects of PET

A

Thrombosis of cerebral arterioles.
Eclampsia,
cerebral haemorrhage, cerebral oedema

98
Q

Fetal effects of PET

A

Impaired uteroplacental circulation
IUGR
hypoxaemia
IUFD.

99
Q

Criteria For Severe Pre-eclampsia

Clinical signs of severity:

A

BP ≥ 160 mmHg systolic and/or ≥ 110 mmHg diastolic
CNS symptoms (headache/ blurred vision/ blindness)
Hyperreflexia/ clonus
Pulmonary oedema
Epigastric / RUQ pain

100
Q

Criteria For Severe Pre-eclampsia

Biological signs of severity:

A 
Oliguria (≤ 500 ml in 24 hours) 
Proteinuria ≥ 5g in 24 hours
Thrombocytopaenia (plt count < 150 000/μL)
Haemolysis
Liver cytolysis / abnormal liver enzymes
101
Q

Umbilical Doppler

A

velocity of umbilical artery blood flow

Normal = low resistance blood flow
Preeclampsia = increased placental resistance leads to abnormal diastolic flow ranging from simply reduced to reversed
102
Q

Cerebral Doppler in case of fetal hypoxia

A

the cerebral doppler will be the last to become abnormal & predictive of short-term poor fetal outcome hypoxia, acidosis, death…

103
Q

PET MATERNAL COMPLICATIONS:

A
  • Placental abruption (1-4%)
  • DIC/ HELLP (10-20%)
  • Pulmonary oedema
  • Acute renal failure
  • Eclampsia (<1%)
  • Liver failure or haemorrhage
  • Death
104
Q

PET FETAL COMPLICATIONS:

A
  • Preterm delivery
  • Fetal intrauterine growth restriction (IUGR)
  • Hypoxia- neurologic injury
  • Perinatal death
105
Q

HELLP Syndrome

Complication of severe preeclampsia

A

Haemolysis (H)
Elevated Liver enzymes (EL)
Low Platelets (LP)

Steroids improve platelet levels

106
Q

PET Evaluation of the severity:

A

BP
Clinical examination: clinical signs of severity
FBC, Coagulation screen, Liver Function Tests, Uric Acid
24 hour urine collection to quantify proteinurea

107
Q

PET Evaluation of fetal well-being:

A 
CTG
US scan 
fetal biometry and weight 
amniotic fluid quantity 
Umbilical and cerebral doppler 
fetal movements
108
Q

Treatment Of Pre-eclampsia

A

Delivery of the fetus and the placenta OVER 37 WKS

Below 34 wks if severe PET or fetal compromise

109
Q

PET monitoring pre-delivery

A

4-hourly BP
Twice weekly monitoring of bloods (liver enzymes, uric acid, platelets
CTG, Biophysical Profile

110
Q

Indications For Delivery in Pre-eclampsia

A

Term gestation (>37 weeks)
Uncontrollable hypertension
Thrombocytopaenia (Plt count <150)
Liver dysfunction (↑AST/ALT)
Symptomatic preeclampsia (headaches, visual disturbance, epigastric pain)
Hyperreflexia/ clonus
Fetal compromise (severe growth restriction/ oligohydramnios/ abnormal umbilical artery Dopplers)
Any complication of severe PET (Abruption, HELLP, renal failure, eclampsia etc.)

111
Q

Drugs used to control acute severe hypertension: (>160mmHg systolic and / or > 110 mmHg diastolic)

A

IV hydralazine
IV labetolol
Short-acting oral nifedipine

112
Q

Drugs used to control chronic hypertension in pregnancy

A

Oral methyldopa
Oral labetolol
Oral sustained-release nifedipine

113
Q

BEWARE of hypotension in pregnancy

A

under 130/80 mmHg –> fetal hypoxia

114
Q

MgSO4

A

during labour and immediately postpartum in women with severe PET

Infusion should be continued for 24 hours after delivery of the baby.

Magnesium Sulphate 4g IV bolus followed by 1g/hr IV infusion used in the acute treatment of eclamptic seizures

115
Q

Monitoring while on MgS04

A

HDU / LW : 1 to 1 care
Continuous CTG if antenatal
Hourly urinary catheter
Strict input / output

116
Q

Signs of magnesium toxicity

A

Respiratory depression
Loss of deep tendon reflexes
If signs of toxicity : stop the infusion + check serum levels

117
Q

What is better for invasive monitoring in PET than CVP

A

PCWP pulmonary capillary wedge pressure

118
Q

PET management

A 
Admit
IV line +/- urinary catheter (if severe)
Evaluation of the severity
Delivery (C section) or expectant management
\+/- antihypertensive treatment 
PO (BP >150/100)  
IV (BP >160/110)
\+/- magnesium sulfate
\+/- steroids if < 34 weeks of gestation (risk of prematurity)

Maternal and fetal monitoring:
– BP
– Fetal monitoring daily
– Repeated US / fetal dopplers

119
Q

aspirin and heparin reduces recurrent pre-eclampsia in women with

A

Thrombophilias

Low-dose aspirin inhibits biosynthesis of platelet thromboxane A2 –> prostacyclin and preventing development of PET

120
Q

Diagnostic Gyn Op Procedures

A

Colposcopy
Diagnostic laparoscopy ± Tubal Patency Testing
Hysteroscopy ± Endometrial Biopsy

121
Q

What is Laparoscopy?

A

The passage of a telescope into the abdominal cavity to allow inspection of pelvic and abdominal organs.

122
Q

Laparoscopy Diagnostic Indications:

A 
Unexplained pelvic pain.
Sub fertility
Investigation of adnexal masses.
Staging of endometriosis.
Dx ectopic
123
Q

Chromopertubation is?

A

Dye is instilled per vaginum into the uterus to assess tubal patency

124
Q

Laparoscopy Therapeutic Indications:

A

Sterilisation
Adhesiolysis
Treatment of endometriosis
Ovarian cystectomy (Benign lesions)
Ectopic pregnancy (salpingectomy/salpingotomy)
Salpingo-oophorectomy (Adnexal Mass, Prophylaxis)
Hysterectomy (TLH, LAVH)
Myomectomy
Tubal surgery ((Salpingostomy, reanastamosis)
Advanced Prolapse Surgery

125
Q

Laparoscopy absolute and relative contraindications

A 
Mechanical or paralytic bowel obstruction
Generalized peritonitis 
Diapharagmatic hernia 
Severe cardiorespiratory disease 
Inflammatory bowel disease 
Massive obesity 
Large abdominal mass 
Advanced pregnancy 
Irreducible external hernia 
Multiple abdominal incisions
126
Q

Laparoscopy: Procedure

A 
General anaesthesia
Semi-lithotomy position and bladder emptied (to avoid injury)
Cervix cannulated 
Skin incision in umbilical base.
Verres needle 
CO2 20-25 mmHg.
Primary trocar is then inserted at umbilicus 
Secondary ports
Gas expelled and instruments withdrawn
127
Q

Laparoscopy: Entry

Different techniques to achieve a pneumoperitoneum

A

Closed
Verres Needle
Direct Trocar Insertion
Optical Trocar

Open
Hasson Technique

128
Q

Complications Of Laparoscopy

A 
Failed entry 
Pre-peritoneal insufflation of gas --> surgical emphysema
Visceral injury- 3/1000
obese and very thin women and adhesions 
Conversion to laparotomy
Infection
Port site hernia 
VTE 
Risk of vascular injury
129
Q

what kind of vascular injury is possible during laparoscopy?

A 
Major vessels (aorta/IVC) from Verres needle/ umbilical trocar
Abdominal wall vessels from lateral port insertion
130
Q

Hysteroscopy And Curettage

A

Passage of a telescope per vaginam through the cervix to allow visualization of the endometrial cavity

Curettage of the cavity provides endometrial tissue for diagnostic purposes

131
Q

Hysteroscopy Diagnostic Indications:

A 
Postmenopausal bleeding.
Abnormal uterine bleeding
Uterine structural abnormalities
Intermenstrual/post coital bleeding despite normal cervical smear
Abnormal pelvic ultrasound findings (endometrial polyps, submucous fibroids)
Subfertility 
Recurrent miscarriages 
Lost intrauterine contraceptive device
132
Q

Hysteroscopy Therapeutic Indications:

A

Removal of an endometrial polyp / retained intrauterine device
Resection of a submucosal fibroid/intrauterine adhesions/septum
First generation endometrial ablation (TCRE, Rollerball)

133
Q

Contra-indications to Hysteroscopy

A

Pelvic infection
Pregnancy
Cervical cancer (heavy uterine bleeding)

134
Q

Complications of Hysteroscopy

A 
Cervical trauma
Creation of a false passage
Uterine Perforation
Hemorrhage
Infection
Failed entry into uterine cavity
Visceral injury
135
Q

List of Surgical Abdominal Procedures:

A 
Laparoscopy
Hysterectomy 
Salpingo-oophorectomy (removal of Fallopian tubes/ ovaries).
Myomectomy
Tubal reconstructive surgery.
Ovarian cystectomy
136
Q

List of Surgical Vaginal Procedures:

A 
Vaginal hysterectomy
Anterior/ Posterior colporrhaphy
Sacrospinous Ligament Fixation
Hysteroscopy (Diagnostic/Operative)
Endometrial Ablation
Cervical Treatment (LLETZ, Polypectomy, McDonald/Shirodkar Suture)
137
Q

Total hysterectomy

A

removal of uterus and cervix

138
Q

Subtotal hysterectomy

A

cervix is conserved

139
Q

Abdominal hysterectomy indications

A

Uterine cancer. (TAH is combined with bilateral salpingoophorectomy (BSO) ± pelvic lymph node dissection)
Ovarian cancer (TAH + BSO + omentectomy ± lymphadenectomy)
Menorrhagia refractory to medical or more conservative surgical therapy
Symptomatic uterine fibroids
Endometriosis refractory

140
Q

Abdominal hysterectomy

procedure

A

Suprapubic transverse/ Pfannenstiel incision.
Round ligaments, Tubo-ovarian, uterine artery, uterosacral pedicles and vaginal angles clamped, cut and ligated.
If the patient is younger than 45 years, ovaries are usually conserved

141
Q

Abdominal hysterectomy lower midline vertical incision only if

A

more extensive exposure is required (e.g. ovarian cancer/ large fibroids).

142
Q

Abdominal hysterectomy complications

A

Haemorrhage , transfusion
Visceral injury (bladder, ureter, bowel)
Infection.
DVT/ PE
Acute menopausal symptoms if ovaries removed

143
Q

Myomectomy

A

Removal of fibroids individually if a woman wishes to conserve her uterus
greater blood loss than hysterectomy
transfusion risk = 5-10%
Risk of hysterectomy

144
Q

Tubal Reconstructive Surgery

A

Tubal occlusion = salpingitis, endometriosis or previous sterilisation

Poor results reflect both the tendency for inflamed tubes to become blocked again = microscopic tubal damage, and impaired cilial motility

Risk of ectopic pregnancy following tubal surgery

145
Q

Vaginal Hysterectomy

preferable to abdominal hysterectomy

A

For
2nd or 3rd degree uterine prolapse.
Any other benign indication for hysterectomy

146
Q

Vaginal Hysterectomy Contraindications:

A

Genital tract malignancy.
Uncertain ovarian pathology.
Large uterine fibroids.
Previous abdominal surgery leading to adhesions.

147
Q

Vaginal Hysterectomy procedure

A

General/spinal anesthesia.
Circumferential incision made on cervix.
Bladder freed and dissected upwards.
Peritoneal cavity is opened anteriorly (uterovesical pouch) and posteriorly (Pouch of Douglas).
Uterosacral, uterine artery and tubo-ovarian pedicles clamped, cut and ligated.
Uterus removed and ovaries inspected to exclude significant ovarian pathology.
Associated vaginal wall prolapse repaired.
Vaginal vault closed.
Vaginal pack and urinary catheter inserted

148
Q

Vaginal Hysterectomy complications

A 
Hemorrhage.
Vault hematoma infected
Urinary tract injury (bladder/ ureter).
Vaginal shortening (particularly if pelvic floor repair performed --> dyspareunia
conversion to abdominal hysterectomy
149
Q

Anterior Colporrhaphy (anterior repair) for cystocoele +/- stress incontinence

A

excision of a portion of vaginal skin and placement of support sutures to pubocervical fascia.
Excess vaginal skin excised & vaginal wall closed.
Urinary catheter placed for 24-48 hours postop

150
Q

Anterior Colporrhaphy Complications:

A

Urinary retention.
Vaginal shortening.
Bladder/ urethral injury.

151
Q

Posterior Colporrhaphy for rectocoele

A

Portion of posterior vaginal wall excised.

Underlying levator ani muscles exposed and joined with interrupted sutures in midline.

152
Q

Posterior Colporrhaphy Complications:

A

Dyspareunia

Due to over-enthusiastic closure of levator ani muscles and removal of excess posterior vaginal wall skin

153
Q

Menorrhagia definition

A

regularly excessive menstrual blood loss that affects the physical, social, emotional or material quality of life of the patient.

154
Q

Menorrhagia Hx

A

Amount, duration of bleeding ,h/o flooding or passage of clots, regularity of periods
Associated symptoms
Dysmenorrhea, intermenstrual or post coital bleeding, pelvic pain
Impact on quality of life
Time off work/school, effect on social life
Other factors that may effect treatment options
Co-morbidities or previous treatments
Past medical history / surgical history
e.g coagulation disorders

155
Q

Menorrhagia Clinical Examination

A

Vital signs, height and weight
General examination, anaemia?
bruising or petechiae
Palpate abdomen for enlarged liver, pelvic masses, pelvic nodes
Speculum examination – visualise cervix, smear if indicated
Bimanual palpation – is uterus mobile or fixed (if fixed could indicate endometriosis)

156
Q

Menorrhagia Investigations

A 
FBC
B-Hcg
Coagulation profile 
Thyroid Function Test 
Trans vaginal ultrasound CT/MRI for endometrial thickness, exclude fibroids and polyps
Endometrial Biopsy 
Hysteroscopy/D &amp; C
157
Q

Endometrial Biopsy

A

To exclude atypical hyperplasia or endometrial carcinoma
Rarely indicated in woman < 40

Method
– Outpatient biopsy - e.g. Pipelle
– Hysteroscopy - outpatient or GA
– D&C - a diagnostic, not a therapeutic procedure

158
Q

Causes Of Abnormal Uterine Bleeding
Figo Classification
PALM

A

P Polyp
A Adenomyosis
L Leiomyoma (Fibroid)
M Malignancy / Hyperplasia

159
Q

Causes Of Abnormal Uterine Bleeding
Figo Classification
COEIN
non-structural causes

A 
C Coagulation disorder
O Ovulatory dysfunction
E Endometrial (primary disorder of mechanisms regulating haemostasis) 
I Infection / Iatrogenic (medications) 
N Not yet known
160
Q

Dysfunctional Uterine Bleeding (DUB)

A

Abnormal bleeding in the absence of organic pathology
extremes of reproductive life
A/W anovulatory cycles

161
Q

Menorrhagia Tx

Non hormonal

A

NSAIDs Mefenamic acid

Antifibrinolytics Tranexemic acid

162
Q

Menorrhagia Tx

Hormonal

A 
LNG-IUS 20 mcg/ day for 5 yrs
COCP
Norethisterone 
Injectable long acting progestogens
GnRH analogues
163
Q

Non hysterectomy surgical treatments for menorrhagia

A

Endometrial Ablation
– impedence-controlled bipolar radiofrequency ablation
– thermal balloon endometrial ablation

– Myomectomy
– Uterine artery embolisation (UAE)

164
Q

Fibroids can be

A 
pedunculated
intramural
intracavitary
submucous
subserous
165
Q

Hysterectomy types

A

Abdominal
• Total or subtotal
• Transverse or midline incision
• ± bilateral salpingo-oophorectomy

Laparoscopic
• LAVH: Laparoscopic Assisted Vaginal Hysterectomy
• TLH: Total Laparoscopic Hysterectomy

Vaginal

166
Q

definitive treatment for menorrhagia?

A

Hysterectomy

167
Q

Uterine Artery Embolization (UAE)

A

treat single or small numbers of fibroids
alternative to myomectomy
via catheter in femoral vein
Causes avascular necrosis of the fibroid(s) = pain

168
Q

UI Predisposing Factors

A
  • Age - especially postmenopausal
  • Obesity
  • Parity – risk increases with parity, especially vaginal deliveries, caesarean not protective
  • Family History
  • Decreased mobility
  • Cognitive impairment/dementia
  • Comorbidities – diabetes, stroke, depression
  • Drugs (diuretics, hypnotics)
  • Caffeine intake, smoking
169
Q

Types of Urinary Incontinence (UI)

A 
Stress UI
Urgency UI [mixed – stress and urgency]
Overflow Incontinence 
Anatomical 
•	Fistula 
 •	Congenital abnormalities
170
Q

Physiology of Micturition

A

Parasympathetic fibers (S2-S4) signal the detrusor muscles to contract (anticholinergic drugs oppose this!)

Sympathetic fibers (T10-L2) signal the detrusor to relax and the bladder neck and urethra to contract

Pudendal nerve (S2-S4) provides motor innervation to urethral sphincter

171
Q

Assessment of Incontinence

A 
History
Physical/pelvic exam 
Urinalysis and other basic tests
Urodynamic testing
Cystourethroscopy
172
Q

Incontinence History

A
  • Relevant urinary symptoms include: frequency, volume, severity, hesitancy, precipitating triggers, nocturia, enuresis, intermittent or slow stream, incomplete emptying, continuous urine leakage, and straining to void
  • Precipitating triggers: cough, exercise, medications, childbirth, surgery
  • Lower genital tract symptoms: pelvic pressure/pain, vaginal dryness, dyspareunia
  • Medications: Diuretics, anti-hypertensives (-blockers)
  • Previous treatments
173
Q

During the last week, how many times did you accidentally leak urine with:

A

Physical activity
Feeling of strong, sudden need to pass urine that did not allow you to get to the toilet fast enough
restricting her normal daily activities?
toilet mapping incontinence pads

174
Q

Voiding Diary

A 
Fluid intake: time, type, amount
Urine output: time, amount
Urine leakage
Triggers  - cough, sneeze, exercise, sex
urgency, dysuria, frequency
Pad 
Excess intake or output
175
Q

Absent perineal sensation with decreased rectal tone =

A

cauda equina syndrome

176
Q

Weakness with hyperreflexia of the lower extremity =

A

upper motor neuron lesion

177
Q

Rectal Examination

A 
mass
Anal sphincter resting tone
Voluntary contraction
Perineal sensation
Fecal impaction
178
Q

Urinalysis

A 
Bacteriuria
Haematuria
Pyuria
Glycosuria
Proteinuria
179
Q

other bladder tests

A 
Postvoid Residual (PVR) > 50mL 
Bladder Stress Test (Cough Test)
Filling urodynamic assessment = Cystometry
Voiding urodynamic assessment = uroflowmetry
180
Q

Cystometry

Stress Incontinence

A

leaking of urine in the presence of raised intra-abdominal pressure and the absence of detrusor activity, the total bladder pressure will be raised at the moment of incontinence but the detrusor pressure is stable

181
Q

Cystometry

Urgency Incontinence

A

the total bladder pressure and the detrusor pressure will be equally elevated at the time of incontinence

182
Q

Voiding urodynamic assessment = uroflowmetry

Dx

A 
outflow obstruction (cystocele) 
weak detrusor (neurological)
183
Q

leaking during physical activity, but can reach the toilet in time

A

Stress incontinence

184
Q

leaking during physical activity, but can reach the toilet in time

A

Stress incontinence

185
Q

leaking during physical activity, can’t reach the toilet in time, urgency, nocturia

A

urge incontinence

186
Q

Stress incontinence causes

A

Urethral Hypermobility - obesity cough trauma

Intrinsic Sphincteric Deficiency - post menopause

187
Q

Stress incontinence management

A 
lifestyle
contributing factors
Pelvic Floor Exercises
Bladder training
Topical vaginal oestrogen
Duloxetine (SNRI)  
Sling Procedures: TVT, TOT
Urethral bulking agents
Burch Colposuspension
188
Q

TVT (Tension-free Vaginal Tape)

A

• Prolene mesh is inserted transvaginally at the level of the mid-urethra using 2 trocars and passed through the retropubic space exiting the abdominal wall

189
Q

Complications of incontinence surgery

A 
vascular injury
bowel/bladder injury
voiding difficulties
erosion of tape through urethra/vagina
urinary retention
urgency incontinence
190
Q

TOT (Transobturator Tape)

A

Prolene mesh is also inserted transvaginally at the level of the mid-urethra but pass instead through the obturator foramina and exit through the skin of the groin area

191
Q

Burch Colposuspension

A

low transverse incision OR laparoscopically

Non-absorbable sutures are placed retropubically to approximate the paravaginal tissues to the ileopectineal ligament

Complications: voiding difficulties, prolapse, detrusor over activity

192
Q

Urgency Urinary Incontinence (UUI) causes

A

detrusor overactivity
neuropathy MS or bladder neck obstruction
spinal cord injury
bladder abnormalities, increased/altered bladder microflora

193
Q

UUI Dx

A

Filling Urodynamic Contraction of the detrusor muscle during bladder filling = detrusor overactivity

194
Q

UUI Tx

A

Lifestyle modifications, pelvic floor exercises +/- biofeedback, and bladder training
Anticholinergic agents (oxybutynin, tolteridine, fesoterodine)
beta 3 agonist (Mirebegron)
Tricyclic antidepressants
Local oestrogen
Cystoscopy + intravesical Botox injections
Clam Ileocystoplasty

195
Q

Anterior Vaginal Prolapse eg

A

Cystourethrocele

Cystocele

196
Q

Apical Vaginal Prolapse eg

A 
Uterovaginal
Vaginal vault (post-hysterectomy)
197
Q

Posterior Vaginal Prolapse eg

A

Rectocele

Enterocele

198
Q

POP aetiology

A 
long 2nd stage of labour
instrumental
large/ many babies
menopause
COPD
obesity
ascites
weight lifting
constipation
199
Q

Pelvic Floor Muscles

A

Levator ani muscle complex
Puborectalis, pubococcygeus, ileococcygeus

Coccygeus + levator ani = pelvic diaphragm

Perineal muscles
Superficial and deep transverse perineal muscles, ischiocavernosus, bulbospongiosus

200
Q

Pelvic Ligaments

A
  1. Cardinal and uterosacral ligaments
  2. Paravaginal attachments along the length of the vagina to the superior fascia of the levator ani muscle
    upper two thirds of vaginal
  3. Perineal body, perineal membrane, and superficial and deep perineal muscles
    distal one third of the vagina
  4. Broad Ligament
201
Q

Anterior Vaginal Prolapse Sx

A

stress urinary incontinence from urethral hypermobility or urinary retention from urethral kinking that causes obstruction

feeling of incomplete emptying with voiding, a slow urinary stream, or urinary urgency

202
Q

Cystocele

A

bulging or descent of the bladder into the upper vaginal wall

203
Q

Urethrocoele

A

descent of the urethra and bladder neck

204
Q

Apical Vaginal Prolapse
(Uterovaginal & Vaginal vault)
POPQ criteria

Stage 1

A

Prolapse remains > 1 cm above hymenal remnants

205
Q

Apical Vaginal Prolapse
(Uterovaginal & Vaginal vault)
POPQ criteria

Stage 2 =

A

Prolapse descends to the introitus

defined as an area extending from 1 cm above to 1 cm below the hymenal remnants

206
Q

Apical Vaginal Prolapse
(Uterovaginal & Vaginal vault)
POPQ criteria

Stage 3 =

A

Descends > 1 cm past the hymenal remnants

but does not represent complete uterine procidentia or complete vaginal vault eversion

207
Q

Apical Vaginal Prolapse
(Uterovaginal & Vaginal vault)
POPQ criteria

Stage 4 =

A

complete uterine procidentia

the vagina and/or uterus are maximally prolapsed with essentially the entire vaginal mucosa everted

208
Q

Vaginal Vault Prolapse may occur following

A

abdominal or vaginal hysterectomy

209
Q

Vaginal Vault Prolapse

Abdominal repair

A

Sacrocolpopexy via laparotomy or laparascopy

210
Q

Vaginal Vault Prolapse Vaginal repair

A

Sacrospinous or uterosacral ligament fixation

211
Q

Rectocele =

A

prolapse of lower posterior vaginal wall usually containing the rectum

212
Q

Enterocele =

A

prolapse of the upper posterior vaginal wall, usually involving the pouch of Douglas and loops of bowel

213
Q

posterior vaginal prolapse

Sx

A

Splinting = need to splint, or place manual pressure on the vagina, rectum, or perineum, to defecate

Constipation or feeling of incomplete emptying

Fecal incontinence

214
Q

Symptoms of POP

A 
Vaginal or pelvic pressure and/or sensation of “something coming down”
Lower back or pelvic pain
worse with prolonged standing 
relieved by lying down
Stress/urge incontinence; nocturia incomplete voiding; splinting or positional changes may be required for urination
rarely retention
constipation/ incomplete voiding
fecal urgency
fecal incontinence obstructive symptoms
Bleeding or chronic vaginal discharge
Sexual dysfunction
215
Q

Clinical exam for POP

A

patient bearing down
Use of Sims speculum to identify uterovaginal or vault prolapse
retractor to splint the opposite vaginal wall
Stress incontinence with coughing
ulceration or vaginal atrophy if postmenopausal
pelvic or abdominal masses
General examination

216
Q

POP Investigations

A 
MSU
Blood Glucose
\+/- Urodynamics
\+/- IVP (procidentia)
Anaesthetic assessment
217
Q

Conservative measures for POP

A 
weight loss
Physiotherapy - pelvic floor exercises!
bladder training
treat chronic cough
stop smoking 
avoid heavy lifting
local oestrogen if postmenopausal
218
Q

Vaginal pessary for POP if…

Review every 6 months and change pessary

A 
Unfit for surgery 
declines surgery
Pregnant
Family not complete
let ulcer healing before surgery
219
Q

Surgery options for POP

Vaginal

Abdominal

A 
Anterior colporrhaphy 
Posterior colpoperineorrhaphy
Manchester (Fothergill) repair
Vaginal hysterectomy
Sacrospinous Ligament Fixation
Mesh/Tape procedures

Burch colposuspension
Colposacropexy

X My Obs & Gyn (10 decks)

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