Final Obs Flashcards
(21 cards)
Describe the management of fibroids [+]
Menorrhagia is the most common problem associated with fibroids and thus management focuses on the treatment of heavy periods:
- Levonorgestrel-releasing intrauterine system (Mirena) - 1st line
- COCP
- NSAIDS
- TXA
Surgical intervention:
- Endometrial ablation
- Myomectomy or hysterectomy
- Uterine artery embolisation (for large fiboids)
Endometrial ablation can be used to destroy the endometrium.
Name a type of endometrial ablation that is most commonly used? [1]
Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation
- This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus.
Describe the management of fibroid degeneration
The mainstay of treatment is conservative management. The patient will need to be assessed at a centre with obstetrics care
Patients should be reassured that fibroids usually regress during the puerperium owing to hormonal withdrawal.
Analgesia
- Acute painful episode usually resolves in 4-7 days
- Paracetamol
- NSAIDS should be used with caution to avoid fetal complications such as premature closure of the ductus arteriosus
In very rare cases, the decision may be made to remove fibroids in the first or second trimester of pregnancy:
- Fibroids causing intractable pain or a torted pedunculated fibroid are rare indications
When would you refer fibroids on to further gynaecology appointments? [5]
Routine referral to Gynaecology:
* Palpable mass on initial examination,
* Fertility or pregnancy issues
* Painful sex, pelvic pain, constipation, frequency
* Fibroids which are palpable abdominally, or intracavity fibroids greater than 12 cm.
* Menorrhagia, symptomatic anaemia
Describe the risk of fibroids in pregnancy:
during pregnancy [5]
during delivery [2]
During Pregnancy
* Increased rates of miscarriage and PTB
* Difficult to measure - growth scans
* Degeneration pain
* Malposition
* Growth restriction
Delivery and Post Partum
* If fibroid below presenting part of head, baby may not come vaginally
* Can make CS very difficult
* Risk of Post Partum Haemorrhage
Describe what happens [1] & what tests [2] are performed when colposcopy occurs
Colposcopy is a procedure that allows optimal visualisation of the cervix.:
- As with the cervical smear a speculum is placed in the vaginal vault and the cervix identified.
- A colposcope (which remains external) is then used to offer a magnified view of the cervix
Tests:
- Schiller’s iodine test involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain.
- Acetic acid causes abnormal cells to appear white. This appearance is described as acetowhite.
- A punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.
White cervical cells after staining in colposcopy would indicate which test has been performed? [1]
What would this indicate? [1]
Acetic acid causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.
What staining has been used on this cervix? [1]
Which test / stain has been performed? [1]
What does this indicate? [1]
Schiller’s (Lugol’s) iodine test involves the application of an iodine-based solution. As the iodine solution is glycophilic, normal glycogen containing squamous epithelium stains brown or black
- CIN and invasive cancer has little glycogen and does not stain. Columnar epithelium is also deficient in glycogen so does not stain.
Describe the different stages of cervical cancer [4]
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina but not lower 1/3 or vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and early stage 1A is? [1]
Cervical intraepithelial neoplasia and early-stage 1A:
- LLETZ or cone biopsy
Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 1B-2A is? [2]
Stage 1B – 2A:
- Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 2B-4A ? [1]
Stage 2B – 4A:
- Chemotherapy and radiotherapy
- Radiotherapy may either be bachytherapy or external beam radiotherapy
- Cisplatin is the commonly used chemotherapeutic agent
Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 4B ? [1]
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
Which MAB may be used in combination with some chemotherapies? [1]
What is its target? [1]
Bevacizumab (Avastin) is a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It is also used in several other types of cancer.
It targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels. Therefore, it reduces the development of new blood vessels. You may also come across this medication as a treatment for wet age-related macular degeneration, where it is injected directly into the patient eye to stop new blood vessels forming on the retina.
Describe complications that may arise due to cervical cancer to the urinary system [2] and bowel dysfunction [2]
Urinary Dysfunction: may arise from the local invasion of the tumour or as a consequence of treatment:
* Ureteral obstruction: Advanced cervical cancer can infiltrate the ureters, causing obstruction and hydronephrosis.
* Urinary incontinence and retention: Surgery and radiation therapy can damage nerves and muscles controlling urinary function, leading to urinary incontinence or retention.
* Vesicovaginal (bladder and vagina) fistula may occur
Cervical cancer and its treatments can also result in bowel dysfunction:
* Obstruction: Direct invasion of the tumour into the rectum, or radiation-induced fibrosis, can cause bowel obstruction.
* Radiation proctitis: Radiation therapy can induce inflammation and damage to the rectum, causing symptoms such as diarrhoea, urgency, and rectal bleeding.
Lecture
Which structures are removed in a radical hysterectomy? [5]
removing the:
- uterus and supporting ligaments
- cervix
- upper vagina
- the pelvic lymph nodes
- sometimes the para-aortic lymph nodes.
Incidence of recurren is 80% in 2 years for cervical cancer.
Where is most likey to reoccur? [3]
Vaginal cuff, pelvis, lymph nodes (paraaortic, supraclavicular), lungs
Describe how you would treat cervical cancer in patients who have a recurrence, but who were initially been treated via:
- surgery [1]
- radiotherapy [1]
Pts previously treated with surgery: give Radiotherapy
Pts previously treated with radiotherapy – Pelvic exenteration for central pelvic recurrence - Removal, vagina, cervix and uterus
* Plus bladder - anterior exenteration
* Plus rectum - posterior exenteration
* Plus bladder and rectum - total exenteration
Describe fertility sparing surgery used for cervical cancer
Radical Trachelectomy:
- removal of the cervix, the upper vagina and pelvic lymph nodes
For early stages only
