Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Laura MRCOG Part 2 > 13) Gynaecological problems - Heavy Menstrual Bleeding > Flashcards

13) Gynaecological problems - Heavy Menstrual Bleeding Flashcards

1
Q

Definitions of heavy menstrual bleeding

A
  • Excessive menstrual loss that occurs regularly (24-35d) which interferes with quality of life (woman’s perception)
  • > 80mL and/or duration of more than 7d (average loss 30-40mL with 90% of women <80mL)
  • Changing pads 1-2 hourly, clots >2.5cm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Incidence of HMB

A

Affects around 20% of women at some point.
5% of women consult GP due to HMB. 20% of outpatient referrals to gynae.
20% of women <60 years have hysterectomy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Causes of HMB

A

50% no cause identified.
Fibroids - 10% of menorrhagia, 40% of severe cases.

PALM COEIN - Polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory, endometrial, iatrogenic, not otherwise specified.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

NICE guidance on examination/investigations required for HMB.

A
  • If history of menorrhagia without other related symptoms can consider pharmacological treatment without physical examination (unless inserting IUS).
  • If other symptoms, needs physical examination.

Investigations:

  • FBC
  • If suspect intracavitary pathology - hysteroscopy
  • If suspect large fibroids - pelvic ultrasound
  • If suspect adenomysosis - TVUS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Management options for HMB

A

Group 1: No identified pathology/fibroids less than 3cm/adenomyosis:

  • Mirena IUS
  • TXA/Mefanamic acid
  • CHC
  • Cyclical oral progestogen (oral NET 5mg TDS from days 5-26 of menstrual cycle)
  • If unsuccessful, refer to consider other options.

Group 2: Fibroids >3cm, or other treatment unsuccessful:

  • Options as above
  • Ulipristal acetate
  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy
  • Endometrial ablation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Effect of GnRH analogues on fibroids

A

36% reduction in size and symptoms after 12 weeks (after discontinuation, menstruation returned 4-8 weeks and size returned 4-6 months)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Incidence of fibroids

A

20-50% of women > 30 years (peak incidence in 40s).

Lifetime prevalence by age 50 70% of white women, 80% black women.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Risk factors for fibroids

A 
Age
Early puberty
Obesity
Black/asian ethnicity
FHx

(Risk reduced by pregnancy and progestogen contraception)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

FIGO classification of fibroids

A

Submucosal:
0 - Pedunculated intracavitary
1 - <50% intramural
2 - >50% intramural

Intramural:
3 - 100% intramural but contacts endometrium
4 - 100% intramural

Subserosal
5 - >50% intramural
6 - <50% intramural
7 - Pedunculated subserosal

8 - Other

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How is uterine artery embolisation performed?

A
  • Conscious sedation and analgesia
  • Percutaneous femoral arterial access
  • Catheter manipulated into uterine artery via anterior division internal iliac artery
  • Embolic agent then injected under fluoroscopic control
  • Takes around 30-90 minutes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Contraindications to uterine artery embolisation

A
  • Current or recent genital tract infection
  • Doubt re: diagnosis
  • Asymptomatic fibroids
  • Pregnancy
  • If a patient would refuse a hysterectomy under any circumstances

Relative contraindications:

  • Concern that pedunculated submucosal or large submucosal fibroids may slough into cavity with risk cervical obstruction
  • Pedunculated subserosal fibroids may also detach and need laparoscopic retrieval
  • If symptoms predominantly bulk, volume reduction may not be adequate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Fertility issues with UAE

A
  • Pregnancy is possible
  • Effect of UAE on fertility unknown
  • Future pregnancies at increased risk of C-section and PPH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Pre-treatment for UAE

A
  • MRI (alters management 22%)
  • Ideally remove IUCD pre-procedure
  • Single dose IV Abx prophylaxis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Complications of UAE

A

Immediate:

  • Local - groin haematoma, arterial thrombosis, dissection, pseudo aneurysm (uncommon)
  • Reaction to contrast (very rare)
  • Spasm leading to incomplete embolisation
  • Non-target embolisation (rare)

Early (within 30d):

  • Post-embolisation syndrome (frequent)
  • UTI (very rare)
  • DVT (very rare)

Late (>30d) - this is majority of complications:

  • Vaginal discharge (16% at 12 months)
  • Fibroid expulsion (10%, 6% requiring additional procedure to remove)
  • Infection (2%, endometritis 0.5%)
  • Hysterectomy (3%)
  • Amenorrhoea (2-7%, >85% over age 45)
  • Change in sexual function (26% improved, 10% reduced)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Features of post-embolisation syndrome

A
  • Pain, fever, nausea, malaise, raised inflammatory markers.
  • Usually self-limiting over 10-14 days.
  • 3-5% require readmission for parenteral analgesia and IVI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management of suspected infection post UAE

A
  • Usually anaerobic
  • Admission for IV Abx and IVI
  • MRI to exclude abscess/fibroid impaction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

In what percentage of women are uterine artery to ovarian artery anastamoses visible

A

46%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are you aiming to destroy in endometrial ablation?

A

Endometrial glands (located at endomyometrial junction) and up to 5mm of myometrium (to get basal glands)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the three first generation endometrial ablation techniques?

A
  • Transcervical resection of endometrium
  • Roller ball endometrial ablation
  • Endometrial laser ablation
20
Q

When is TCRE preferred and how is it done?

A
  • Preferred when hysteroscopic myomectomy required in conjunction with ablation
  • 3mm electrosurgical loop with operative resectoscope. Glycine if monopolar. Saline if bipolar.
21
Q

When is roller ball endometrial ablation preferred and how is it done?

A
  • Preferred if >1 CS, previous uterine surgery or congenital malformation or repeat ablations.
  • Roller ball electrode through resectoscope
22
Q

What are the second generation endometrial ablation techniques?

A
  • Thermal balloon ablation
  • Bipolar radiofrequency endometrial ablation (Novasure)
  • Hydrothermal ablation
23
Q

When are second generation endometrial ablation techniques suitable?

A
  • Uterus no larger than 10-12 week size and sub mucous fibroids <3cm
24
Q

How does thermal balloon ablation work?

A
  • Catheter and silicone balloon filled with hot liquid at high pressure
  • Combination high temp and high pressure - endovascular coagulation and fibrosis
  • Newer devices keep constant pressure despite uterine contraction/relaxation
25
Q

Contraindications to thermal balloon ablation

A

Classical CS

Transmural myomectomy

26
Q

How does Novasure ablation work?

A
  • Delivers radio frequency energy to endometrium until tissue impedance reaches 50 ohms.
  • Electrode array conforms to contour of cavity
  • Cavity integrity test uses small amount CO2 to check leak/perforation
27
Q

How does hydrothermal ablation work?

A
  • Under direct hysteroscopic vision. Circulating heated saline at 90 degrees in endometrial cavity.
  • Need tight seal at cervix to prevent burns
  • Need to induce endometrial thinning with GnRH analogues prior to treatment
28
Q

Pregnancy rate and complications post endometrial ablation

A
  • Pregnancy rate 0.7% (need effective contraception)

- Complications: miscarriage, ectopic, PTB, IUGR, abnormally invasive placenta, uterine rupture, CS, PPH

29
Q

Success rates endometrial ablation

A

80% satisfaction
50% amenorrhoea
20% re-operation
(No difference between 1st and 2nd generation in satisfaction)

30
Q

Complications with endometrial ablation

A

Peri-operative complications (around 1% risk each):

  • Haemorrhage
  • Perforation
  • Cervical lacerations
  • Endometritis
  • Haematometra

Other:

  • TURP syndrome secondary to glycine overload (stop procedure at 1.5L deficit)
  • Post ablation syndrome - new onset/significant worsening of pain during menstruation as a result of obstruction of menstruation following scarring and synechiae formation
  • Post ablation tubal sterilisation syndrome (6-8%): when sterilisation combined with ablation, cyclical pain, retrograde menstruation into obstructed tube
31
Q

Technique options for hysteroscopic myomectomy

A
  • Surgical resectoscope to resect chips from fibroid
  • Cold loop technique to enucleate fibroid in total into cavity
  • Miniature morcellators down hysteroscope (TruClear/Myosure)
32
Q

What percentage of women have continuing cyclical bleeding after subtotal hysterectomy?

A

5%

33
Q

What percentage of benign hysterectomies are performed open?

A

60%

34
Q

Indications for ulipristal acetate

A
  • Intermittent treatment (each treatment course not exceeding 3m and should only be repeated after a break in treatment) of moderate–> severe symptoms of uterine fibroids in women of reproductive age who are not eligible for surgery.
  • One course of pre-op treatment
35
Q

LFT monitoring whilst on ulipristal acetate (esmya)

A
  • Before initiating each course (don’t do it if ALT/AST>2ULN)
  • Monthly during first two courses
  • 2-4 weeks after end of each course
  • Stop essay and monitor closely if ALT/AST>3ULN
36
Q

Success rates for uterine artery embolisation

A

80-90% asymptomatic or significantly improved symptoms at one year with 40-70% reduction in fibroid volume.

Approx 1/3 will require re-intervention.

37
Q

Over what time period is the learning curve for laparoscopic myomectomies

A

4 years

38
Q

What is the risk of LMS in specimen presumed to be a fibroid?

A

<30 years: <1 in 500
40-45: 1 in 400
50-55: 1 in 200
75-80: 1 in 100

39
Q

Risk factors for LMS

A 
Age
African Origin
Tamoxifen > 5 years
Pelvic radiation
Hereditary predisposition
40
Q

Methods to minimise blood loss during laparoscopic myomectomy

A

Pre-op:

  • GnRH analogues significantly shrink but can disrupt surgical planes
  • Ulipristal for shrinkage

Intra-op:

  • Pre-op misoprostol (400micrograms PV)
  • Vasopressin or bupivicaine/adrenaline into either pericapsuar space or uterovesical fold adjacent to uterine arteries
41
Q

How to close uterus after laparoscopic myomectomy?

A

If cavity breached - repair 3-0 monocryl
Myometrial closure (multilayer) can use barbed suture
Serosal closure - continuous 2-0 or 3-0 monofilament

42
Q

Risk of future uterine rupture after laparoscopic myomectomy?

A

1%

43
Q

Rate of conversion to open after lap myomectomy

A

1%

44
Q

Risk of emergency hysterectomy after lap myomectomy

A

0.3%

45
Q

Overall complication rate (+major complications) for laparoscopic myomectomy

A

11% (2% major)

46
Q

Risk of parasitic myomata/disseminated peritoneal leiomyomatosis

A

0.1-1%

47
Q

In what percentage of cases is the diagnosis of LMS obscured by unconfined corporeal morcellation?

A

20%

Laura MRCOG Part 2 (56 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions