Acute Gynae Flashcards

Question

What is an ovarian cyst and what are some types[3]? What are some RFs for getting ovarian cysts? What are rokitansky protuberances?

Answer 1

Fluid filled sac in ovarian tissue - > 90% ovarian tumours are benign - > 8% premenopausal women have large cysts RFs = PCOS, endometriosis (also pregnancy* i.e. luteal cysts seen in early pregnancy) Types of ovarian cyst (benign): - Physiological: Follicular cyst (commonest, lined by granulosa cells) and Corpus luteal cyst* (lined by luteal cells) - Benign germ cell: Dermoid cyst/mature cystic teratoma - -> lined by epithelial cells - -> most common benign tumour in those <30 - -> often asymptomatic but most likely to TORT! - -> May see 'rokitansky protuberances on USS' which are white shiny masses that protrude out - Benign epithelial: serous cystadenoma and mucinous cystadenoma (usually very LARGE)

Answer 2

Most benign ovarian tumours are cystic - finding solid elements increases likelihood of malignancy

Answer 3

Ovarian cysts are very common in premenopausal women, due to fluctuations in hormones of the menstrual cycle Cysts in post-menopausal women should make you consider malignancy

Answer 4

Sx: - > Lower abdominal pain - > Distension/swelling with pressure symptoms (frequency, urgency) - > Deep dyspareunia - > Acute abdomen if rupture/ haemorrhagic/torsion!! Rule out red flags/cancer Sx = early satiety, reduced appetite, weight loss, ascites

Answer 5

Ix: - > If acutely unwell, A-E approach - > Pregnancy test - > TVUSS - ---> outcome dependent on menopause status: - --> PRE-menopausal: if simple cyst, manage depending on size but if complex and <40y then request LDH, aFP and b-HCG levels - --> POST-menopausal: both simple and complex cysts require a Ca125 done and RMI calculated

Answer 6

Mx: Pre-menopausal women - Simple cyst/unilobular: - -> <5cm = no f/u required - -> 5-7cm = repeat USS yearly - -> >7cm = further imaging e.g. MRI +/- surgery Indications for watchful waiting = unilateral, normal Ca125, no free fluid, if pre/post-menstrual period, no solid parts (unilocular) - IF recurrent or unresolved, then can give COCP as preventing ovulation will prevent recurring cysts - IF recurrent, sustained >5cm or suspicious/multiloculated then surgical management (laparoscopic cystectomy) is usually curative Post-menopausal women: - RMI <200: - -> if all 3 of: asymptomatic, simple cyst, <5cm, unilocular and unilateral then = repeat USS and Ca125 in 4-6m (by then it will have either resolved, repeat if unchanged BUT if changed by then, laparoscopic cystectomy) - -> BSO = indicated in those with any of: symptomatic, non-simple features, >5cm, multilocular and bilateral - RMI >200: - -> CT-AP and MDT management - -> TAH + BSO +/- omentectomy

Answer 7

- Cyst rupture - -> Common in functional cysts - -> Conservatively managed with pain relief and watchful waiting - -> IF evidence of active bleeding, laparoscopy (+/- cautery) may be indicated - Ovarian torsion - -> if >5cm - -> Commonly in dermoid cysts - Subfertility - Malignant change - Oopherectomy

Answer 8

Twisting of the ovaries - a complication of ovarian cysts or tumours - > Dermoid cysts are the MOST likely, whereas endometriomas are the least likely - > Ovarian cysts >5cm are at risk of torsion RFs: - > Ovarian cysts or tumours - > More likely in pregnancy - > Tubal ligation - > Long ovarian ligaments (i.e. younger girls before menarche have longer infundibuloligaments)

Answer 9

Sx: - Sudden onset severe RIF or LIF pain (unlikely to radiate to shoulder tip like ectopic) - N+Vomiting - Localised tenderness and palpable pelvic mass

Answer 10

Ix: - > A to E approach if acutely unwell - > Pregnancy test !! - > Bimanual may show an adnexal mass - > Speculum if suspecting PID - > Urinalysis - to rule out uterteric colic - > Bloods - FBC may show high WCC + surgery bloods - > USS with Dopplers is KEY (TVUSS>Abdo, unless children) - shows ovary oedema and free fluid in pelvis, and 'whirlpool sign'. Doppler may show reduced blood flow (ischaemia) Mx: - > Laparoscopy is the only way to definitively diagnose - > Decision is made in surgery to either untwist + fix ovary (detorsion) or also remove the affected ovary (oophorectomy)

Answer 11

Risks: - > Ischaemia and necrosis of the ovary - > Abscess formation and sepsis - > Sub/infertility and menopause if no existing ovary left - > If not removed, may rupture causing peritonitis and adhesions

Answer 12

FGM = female genital mutilation where there is partial or total removal of the external female genitalia Type 1 = removing part/all of the clitoris Type 2 = excision of the clitoris and labia minora +/- labia majora Type 3 = infibulation where there is narrowing of the vaginal opening but cutting and repositioning the labia and creating a seal Other: cutting, scraping, burning, pricking and piercing 2% women in London, 100,000 women and girls in England + Wales - Often in younger girls, pre-puberty ~15y

Answer 13

Sx: - Constant pain - Dyspareunia - Incontinence - Recurrent infections - Psychological effects e.g. depression, flashbacks and SH - Bleeding, cysts and abscesses

Answer 14

Mx: - Deinfibulation --> offered to those who are unable to have sex, pass urine or pregnant women at risk during recovery + analgesia - Must be recorded in notes - If <18yo, then must report to police and social services (via 101) - If 18+ then no obligatory duty to report (aside from notes) and may offer deinfibulation Complications: - Repeated infections --> infertility - Life-threatening complications during labour and childbirth - Haemorrhage, urinary retention, menstrual difficulties, HIV, HBV Note: REINFIBULATION e.g. after childbirth is illegal in the UK!

Answer 15

Presence of intrauterine adhesions within the uterus which occlude the uterine cavity Due to adhesions/scar tissue which may be secondary to surgery, trauma (birth) or severe infection (endometritis) Occurs in 5-40% of dilation and curettage i.e. after miscarriages/RPC RFs: - Endometrial resection - D&C for miscarriage or TOP - Surgery - myomectomy , C section - Endometriosis

Answer 16

Sx: - Secondary amenorrhoea - Cyclical abdominal pain/dysmenorrhoea - Significantly lighter periods - Subfertility/infertility

Answer 17

Ix: - Hysteroscopy [gold standard - may involve dissection and Tx of adhesions] - Sonohysterography - uterus filled with fluid + pelvic USS - Hysterosalpingography (contrast in uterus + XR) - MRI ``` Mx: -> Hysteroscopic ablation [-> Post-op copper IUD then: -> PO oestrogens to induce endometrial proliferation (2-3m) and reassess cavity ```

Answer 18

Dryness and atrophy of the vagina due to lack of oestrogen - > AKA genitourinary syndrome of menopause - > Oestrogen acts on the vaginal epithelium and urinary track to ensure elasticity, secretions and thickening - > Post-menopause, women therefore can become dry, thin and less elastic [+changes in flora and pH which may predispose to infection] 10-40% of post-menopausal women

Answer 19

Sx: - > Vaginal dryness - > Dyspareunia - > Itching - > Bleeding due to local inflammation - > O/E: pale, thin vaginal walls with loss of skin folds, dryness and erythema, sparse pubic hair CONSIDER AV in women presenting with recurrent UTIs, stress incontinence or prolapses as oestrogen required to ensure connective tissue support

Answer 20

Ix: - > Mainly clinical based on Hx and O/E findings - > Swabs + urine dip/MC+S to rule out infection - > Biopsy if considering potential malignancy/ulcers Mx: - > Vaginal lubricants for dryness [Sylk, Replens, YES] - > Topical oestrogen [creams, pessaries, tablets or rings] - ---> However, ensure no CI e.g. VTE, angina or breast cancer! SE's same as systemic HRT [endometrial cancer etc] so ensure on lowest dos and not for too long// f/u at least annually with view to stopping when possible

Answer 21

Inflammation and infection of the pelvic organs, resulting from ascending infection of the genital tract [e.g. endometritis, oophoritis, salpingitis etc] Most common cause = *Chlamydia Trachomatis* ``` Other common causes: [STIs] -> Neisseria gonorrhoea - tends to produce more severe PID -> Mycoplasma genitalium [Non-STIs] -> Gardnerella - associated with BV -> H. influenzae -> E. coli ```

Answer 22

RFs: - > Multiple sexual partners - > Early age of first coitus - > Not using barrier contraception and/or use of IUD/IUS - > Young age e.g. <25yo - > Existing STI - > Previous PID Sx: - May be asymptomatic - Infertility - Chronic pelvic pain/lower abdominal [>bilateral] - Abnormal discharge - Abnormal bleeding i.e. IMB/PCB [both C+G cause bloody discharge but C more common] - Fever - Dyspareunia - O/E - cervical motion tenderness, pelvic tenderness, purulent discharge, fever, signs of sepsis

Answer 23

Ix: - Abdominal examination - Bimanual (cervical excitation, check for adnexal assess such as tubo-ovarian abscesses) - Speculum (signs of inflammation or discharge) + triple swabs [2x endocervical NAAT and 1x HVS] - Urinary pregnancy test to rule out ectopic pregnancy - If febrile, bloods (FBC, CRP, ESR)

Answer 24

Mx: - > Assess patient for admission i.e. if septic, pyrexial >38 degrees; otherwise treated in the community as OP --> see within 2-3d to see Abx response --> f/u in 2-4w - > Start Abx before swabs come back if you suspect PID - > OP Abx include [an example from BASSH guidelines]: - --> 500mg IM Ceftriaxone single dose [covers Gonorrhoea] - --> 100mg BD PO Doxycycline for 14d [covers Chlamydia and Mycoplasma] - --> 400mg Metronidazole BD PO for 14d [covers anaerobes] Inpatient - if pyrexial OR 2-3d later no response to Abx: - > 1st line = IV cefotixin + doxycycline - > 2nd line = IV clindamycin or gentamycin -> Other: STI screening, contact tracing, discuss contraception, removal of any IUD! and avoid sex until treated Note: consider referral to GUM clinic

Answer 25

Complications: - Sepsis, abscess - Infertility - Ectopic pregnancies (paralyse cilia in Fallopian tubes) - Fitz-Hugh-Curtis syndrome

Answer 26

FHC syndrome is inflammation and infection of the liver capsule [Glisson's capsule] --> adhesions between the liver and peritoneum --> - Complication of PID - Results in RUQ pain - Laparoscopy and adhesion removal may be used as management

Answer 27

Endocervical: - NAAT for Chlaymdia, Gonorrhoea (sometimes Mycoplasma if available) HVS: - BV - Trichomonas V - Candida

Answer 28

Cyst or abscess of Bartholin's gland (greater vestibular glands) Physiology: - > Bartholins glands are a pair of glands, placed either side of the posterior vaginal introitus, inferiorly - > They normally secrete mucus to help with vaginal lubrication. They are usually pea sized and NOT palpable - > The ducts may get blocked within the gland, causing a cyst (1-4cm), usually unilateral - > These cysts may get infected, forming a Bartholin's abscess which are usually red, hot and potentially draining pus

Answer 29

Sx: - > Unilateral labial swelling, often asymptomatic or painless - > If infected, you may see the abscess with signs of infection, fever, dyspareunia, pain on sitting or walking Ix/Dx: - Clinical Dx - If >40yo, consider vulval biopsy - If infected, MC+S from abscess [most are sterile but may help organism differentiation]

Answer 30

RFs: - Nulliparous - Previous Bartholin's cyst - Sexually active

Answer 31

Mx: -> Conservative, if the patient is well: good hygiene, warm compress and analgesia and they usually resolve [Usually want to avoid incision due to often recurrence] -> Flucloxacillin OD if infected abscess/systemically unwell Surgical: 1st line if symptomatic = marsupialisation or word catheter: -> Consider incision and draining + 'Word catheter' [where tissue heals around the balloon, which is in the cyst cavity post-drainage, and then taken out at a later date] -> Marsupialisation = forming an open pouch to stop the cyst from reforming by incising and draining the cyst, the suturing the sides open Complications: - Rupture - Recurrence - Sepsis/Abscess

Answer 32

Endocervix = columnar epithelium --> Transformational Zone --> Ectocervix = squamous epithelium

Answer 33

When the columnar epithelium of the endocervix extends out to the ectocervix Therefore, this area is more fragile and prone to trauma hence why they may present with PCB (+ increased vaginal discharge, bleeding, dyspareunia) RFs: linked to raised oestrogen levels - > Younger women - > COCP use - > Pregnancy You will be able to see ectropion on speculum examination Mx - reassurance; if asymptomatic, no treatment required. If bleeding is problematic, then may be treated with cauterisation using AgNO3 or cold coagulation during colposcopy + stop oestrogen-based contraceptives

Answer 34

Cervical polyp: overgrowth of endocervical columnar epithelium [benign, solitary, may be linked to oestrogen] - > Ix: speculum - > Mx: reassurance, removal and send to histology Endometrial polyp: overgrowth of endometrial tissue - > Ix: TVUSS; outpatient hysterectomy and saline infusion sonography are most accurate - > Mx: may resolve spontaneously if small; polypectomy to alleviate symptoms/exclude EH or cancer

Answer 35

Spontaneous loss of a pregnancy before 24w ``` Early = <12w Late = 12-24w ``` After 24, the loss/PV bleeding is an APH

Answer 36

Affects up to 25% (1/4) pregnancies so v common Causes: - > Usually 1st trimester miscarriages are due to chromosomal abnormalities - > Medical/endocrine disorders e.g. APS, thrombophillia - > Uterine abnormalities (bicornuate or septate) - > Causes of late miscarriages may include cervical incompetence (e.g. post-LLETZ or cone biopsy) - > Infections - > Drugs - > Increasing risk with age

Answer 37

1. Complete - PV bleeding - Cervical os = closed - Expelled all products of conception 2. Incomplete - PV bleeding and cramping - Cervical os = dilated - Some products expelled 3. Threatened - PV bleeding - FHR activity - Cervical os = closed but soft 4. Inevitable - PV bleeding and cramping - ROM - Cervical os = dilated - May feel some products of conception in cervix 5. Missed - No vaginal bleeding - No FHR on USS or empty sac - Cervical os = closed [6] - Recurrent = 3 or more consecutive spontaneous miscarriages occurring in the 1st trimester with the same biological father, which may/may not follow a successful birth -> no cause found in 50%; prognosis for future successful pregnancy is 60% after 3 miscarriages

Answer 38

Sx: - > PV bleeding - > Crampy abdominal pain, fever - > O/E Speculum - active bleeding, os open or closed or see any products - > Assess if any signs of shock

Answer 39

Ix: - Pregnancy test - Speculum - Os, bleeding - Bloods - FBC, G&S, Rhesus status - TVUSS - look for FH --> CRL (>7mm) --> MSD (>25mm) Usually, you require a second sonographer opinion but otherwise rescan in 1/2w if unsure

Answer 40

Pregnancy of unknown viability - > A definite intrauterine gestation sac without evidence of a viable foetus when: - > CRL <7mm and no FH - > MSD <25mm in an empty sac i. e. we know where the pregnancy is but not if it will continue

Answer 41

Ix: - > Pelvic USS for structural abnormalities - > APS antibodies, (anticardiolipin antibodies) - > Cytogenetic analysis of products of conception - > Peripheral blood karyotyping of both parents Tx - > APS = Aspirin/LMWH (Warfarin is used in non-pregnant individuals) - > Surgical Tx of uterine abnormalities - > Gamete donation/PGD for chromosomal translocation However, cause is often never found

Answer 42

Mx: Note: G-ER or EPAU referral if >6w pregnant + ensure to rule out ectopic 1. Expectant - -> Highly effective in women with an incomplete miscarriage, however may be less effective if sac is intact - > Wait 7-14d to await the events - > Repeat pregnancy test in 3w to see if it is passed; return if positive - > Repeat USS after 2w to ensure complete miscarriage - > Safety net (pain is like severe period pain, can take ibuprofen/para to help but if really bad, come back in, also if heavy bleeding i.e. >3 heavy sanitary pads soaked within 1h OR passing a clot larger than your hand) 2. Medical - > 800mcg Misoprostol PV for missed mc - > 600mcg Misoprostol PV for incomplete mc - > Started within 24h - > Accompany with analgesia - > Counsel women on what to expect + safety net - > Pregnancy test after 3w 3. Surgical -> Surgical management of miscarriage (SMM) which is performed under GA and involves suction an curettage, sent for histology OR -> Manual vacuum aspiration (MVA) done under LA in OP setting ++++ ANTI-D for Rh- women (as if <12w and have had uterine evacuation either medically or surgically or ectopic pregnancies) -> Given within first 72h following surgery ++++ Psychological support - > Counsel about options - > Miscarriage association website and support groups - > Safety netting is key

Answer 43

- > If pain becomes more severe, uncontrolled with ibuprofen/paracetamol - > If experiencing heavy bleeding i.e. >3 heavy sanitary pads soaked within 1h OR passing a clot larger than your hand then seek medical help immediately - > Regardless

Answer 44

HPV 6 + 11 --> benign genital warts HPV 16 + 18 --> CIN, VIN, cancer risks Transmission is by physical or sexual contact, occasionally vertical RFs = unprotected sexual intercourse, immunosuppression, multiple sexual partners, no barrier contraception

Answer 45

50% of sexually active adults have HPV Sx: - Asymptomatic - Genital warts on vulva, vagina, cervix and anus (painless, may itch/bleed) - Pink/red/brown warty papules - Four types - -> Small popular - -> Cauliflower - -> Keratotic - -> Flat papule/plaques

Answer 46

Dx - > Clinical Dx for warts (dermatoscope) - > Histology (biopsy) and cytology (smear) Tx Medical: -> Imiquimod cream *But CI in pregnancy Surgical - > Electrocautery (/Plasmajet) - > Cryotherapy, laser Prevention = HPV vaccine @ 12-13yo (Gardasil = 4 strains)

Answer 47

Chronic inflammatory skin condition, usually affecting the vulva and perineum - > Those <10yo and >60yo - > Associated with autoimmunity and genetics

Answer 48

Sx: - Itching and discomfort, worse at night - Dyspareunia - Fragile, thin skin or thickened (+ blister formation) - O/E = white patches on the skin, may become cracked and sore

Answer 49

Tx: - > Steroid ointment cream Betamethasone/Dermovate (Clobetasol propionate 0.05%), 2nd line = tacrolimus (topical calcineurin inhibitor) and biopsy - > Also emollient use advised along with steroids and for maintenance + as soap sub - > F/u every 3-6m by dermatologist/experienced gynaecologist - > Cannot be completely cured but effectively managed Risk of vulval cancer (SCC) - 1/20, therefore patients may undergo vulval mapping to monitor progression

Answer 50

Not strictly a gynaecological condition, but another skin condition where there are clusters of shiny, red-purple blotches which are sore, with white lines (Wickham's striae) on the surface - > Dx is clinical - > Tx is same as LS; steroid ointment or tacrolimus

Answer 51

Infection of the breast - usually caused S. aureus - > Affects 1/10 breastfeeding women due to backlog of milk within ducts - > Associated with nipple injury and smoking

Answer 52

Sx: - Nipple discharge (white/bloody streaks) - Red, tender breast with possible abscess (burning pain) - Fever - Coryzal symptoms - aches, chills Diagnosis = clinical

Answer 53

Mx: -> Consider admission if signs of sepsis/HC, rapid progression or immunocompromised Non-severe --> simple analgesia, supportive care (warm compress, massage breast), continue breastfeeding; if not improving after 24h (NHS) then see GP for Abx Severe or non-lactational --> - > Infected nipple fissure, S/S not improved after 12-24h, milk culture positive - > Flucloxacillin 500mg QDS PO; if doesn't improve after 48h with Abx then use Co-amoxiclav - > MRSA - use Trimethoprim - > Abscess is diagnosed with USS which is then incised and drained, and fluid is cultured

Answer 54

Pre-menstrual syndrome - Distressing symptoms occurring in the luteal phase of the menstrual cycle (in the absence of pathology) - Affects up to 90% women - RF's = smoking, obesity, lack of exercise, FHx

Answer 55

Sx: - Mood swings - Poor concentration, anxiety - Lack of energy - Breast tenderness - Disturbed sleep - Bloating - Headache Dx = requires a symptom diary over 2 cycles

Answer 56

Mx: -> All patients receive conservative advice such as painkillers, stress reduction, smoking cessation and alcohol reduction, sleep hygiene and regular exercise Moderate PMS - some impact on person, social and professional life - -> COCP - cyclical or continuous - -> +/- CBT Referral - -> + Paracetamol/NSAIDs Severe PMS [Premenstrual dysphoric disorder] - withdrawal from social and professional activities, affects normal functioning - -> SSRI - trial for 3m - -> +/- CBT Referral - -> Alternatives include GnRH analogues, transdermal oestrogen and surgery

Answer 57

Toxic Shock Syndrome -> Septicaemia from toxin TSST1 produced by Staph [and Strep bacteria - inflammatory cascade] Caused by multi system inflammatory response to bacterial exotoxins -> Tampons are a risk factor, overuse without changing BUT it is rare [40 per year; 17/100,000 users]

Answer 58

Sx: - > Fever, up to 39+ - > D+V - > Diffuse red macular rash - > Shock, collapse - > Desquamation of palms and soles - > Myalgia, sore throat, headache

Answer 59

A to E approach - > Bloods - FBC (low plt, high WCC), U&Es, LFTs, CRP, CK - > Blood cultures - > HVS, culture of tampon Mx: - > ABC + remove tampon - > BS antibiotics IV 5-15% mortality -> Complications include septic shock, DIC, ARDs and death

Answer 60

Pruritus vulvae - itchy vulva, which may be caused by a variety of things: - > Infection e.g. vulvovaginal candidiasis - > Atrophic vaginitis - 10-40% menopausal women - > Eczema - > Contact dermatitis ``` Presents: VC = itching, burning, erythema and oedema of the vestibule and labia + thick, white curd-like discharge [if chronic, then may have lichenification and grey sheen of epithelial cells also] AV = soreness, thin skin, itching, dyspareunia Vulvar vestibulitis = may cause introital dyspareunia (on contact or after sex), soreness, burning ```

Answer 61

Ix: -> Vulvovaginal candidiasis = wet-mount test or KOH preparation -> Atrophic vaginitis = vaginal pH and wet-mount test Wet-mount is a sample of discharge which is observed for causes of vaginitis

Answer 62

Mx - depends on cause: - > VC = antifungals e.g. ketoconazole/ fluconazole, clotrimazole suppositories - > AV = topical oestrogen/HRT, lubricants - > Contact dermatitis = remove agent, 1% hydrocortisone cream or bethametasone if moderate

Answer 63

A woman of reproductive age who has not conceived after 1y of regular, unprotected sexual intercourse -> Affects 1 in 6 couples, commoner with increased maternal age 85% of couples will conceive after 1y of unprotected sex (15% will not)

Answer 64

If couple has tried to conceive for ~12m without success | -> This can be reduced to 6m if woman is 35+

Answer 65

Women (uterine, tubal or ovulation) = ~50% (10, 15 + 25%) Male, sperm problems = 30% Unexplained = 20% BUT ~40% of infertile couples have mix of female and male causes Female causes: - > Ovarian = Hypothalamic amenorrhoea, PCOS, POI, primary hypothyroidism, prolactinoma - > Tubal = PID, adhesions, endometriosis - > Uterine = abnormalities, fibroids - > Genetic = chromosomal abnormalities e.g. Turners - > Lifestyle = smoking, method of sex Male causes: - > Structural = VARICOCELE, cryptorchidism, CF and absence of vas deferens - > Hypothalamic - > Function = ED - > Lifestyle = smoking, BMI>30, EtOH - > Genetic = Klinefelter, Kallman's

Answer 66

Ix: - > BMI (if low or high) - > Chlamydia screening for both - > Semen analysis (x2, 3m apart) - > Female hormone testing - > Rubella immunity in mother Female hormone testing: - Serum LH and FSH on day 2-5 of cycle - Serum progesterone on day 21 [if 28d cycle] OR 7 days before next period - Anti-Mullerian hormone (produced by granulosa cells so isn't altered by hormones) - TFTs, if suggestive Sx - Prolactin, if Sx of galactorrhea or amenorrhoea Other tests [often in secondary care] - > USS - > Hysterosalpingogram - used to assess the shape of the uterus and potency of fallopian tubes - > Laparoscopy and dye test - observe any tubal obstruction + treat endometriosis/adhesions Results: - -> High FSH = POI, poor ovarian reserve [pituitary producing more FSH to stimulate follicular development] - -> High LH = may be PCOS (esp raised LH:FSH) - -> Raised progesterone on day 21 indicates ovulation has occurred, the corpus lutetum has formed and has started secreting progesterone - -> AMH is an accurate measure of ovarian reserve so high level indicates good reserve

Answer 67

Mx advice: - > Generally wait for 12m (6m if 35+) before investigating as its quite common - > Difficulty is common, affects 1/6 for 1y - > Aim for healthy BMI (20-25) - > Avoid smoking and drinking excessive alcohol - > Reduce stress as may negatively affect libido and relationship - also avoid timing sex as this can place strain also and it isn't necessary to time with ovulation anyway - > Aim for intercourse very 2-3d (let sperm count recover) - > Woman should be taking 400mcg folic acid daily

Answer 68

Mx depends on the cause: Ovulation issues - -> Weight loss i.e. PCOS - -> Clomifene, anti-oestrogen SERM, to stimulate ovulation (+/- metformin) - given on days 2-6 of the cycle - -> Letrozole may be used instead of clomiphene (aromatase inhibitor with anti-oestrogen effects) - > Other: gonadotrophins, ovarian drilling Other: - > Tubal cannulation during a hysterosalpingogram - > Surgical options for tubal or uterine abnormalities - > IVF Sperm: - -> Surgical sperm removal if due to blockage/surgical correction of obstruction - > Sperm motility issues/DM/ED/oligospermia = intracytoplasmic sperm injection (ICSI) - most common Tx for male infertility - -> Intra-uterine insemination (unclear if better than intercourse however) - > Donor insemination if male infertility (azoospermia)

Answer 69

Ovarian hyperstimulation syndrome - > Ovaries become hyper stimulated e.g. w gonadotrophins or IVF - > Ovarian enlargement, increased vascular permeability, pro-thrombotic state - > Presents with abdominal pain, distension, N+V, SOB, oedema/ascites - > Mx is supportive, VTE prophylaxis and fluid replacement

Acute Gynae Flashcards

(93 cards)