Gynae Flashcards
(27 cards)
What is the path of the ureter
Crosses pelvic brim at level of common iliac bifurcation
Travels medial and posterior to IP vessels
Travels in lateral pelvic sidewall medial to internal iliac
Travels in medial leaf of broad ligament
Crossed by uterine artery at level of internal os
Lateral to uterosacral ligaments
Through cardinal ligament (ureteric tunnel) and into the bladder before trigone
What levels can the ureter be injured at and at which steps of a hysterectomy?
Crosses pelvic brim with ligation of IP if ovaries are being taken
As crossed by uterine artery as uterine artery is ligated at level of internal os
Lateral aspect of cardinal ligament as being taken
Lateral to uterosacrals as vaginal vault is being sutured
What are the branches of the internal iliac?
Iliolumbar
Lateral sacral
Superior gluteal
Inferior gluteal Internal pudendal Uterine Middle rectal Obturator Vaginal and inferior vesical Umbilical remnant and superior vesical
Describe Palmer’s point entry
Anaesthetist insert NG tube to empty stomach
Percuss to exclude hepatosplenomegaly
Landmark is 3cm below inferior costal margin in midclavicular line on the L
Insertion with a verres needle with appropriate safety checks, ensure initial pressure <8mmHg x 3
Establishment of pneumoperitoneum 20mmHg
Optical direct entry once established
Visualisation of anatomy at umbilicus
What are the benefits of MHT?
Most effective treatment for vasomotor symptoms
Improvement in genitourinary symptoms
Reduction in osteoporosis and assoc fractures
Reduction in cardiovascular disease - WoO
Reduction in T2DM onset
Reduction in colorectal cancer
Reduction in all-cause mortality - WoO
WoO = Window of opportunity
What are the risks of MHT?
VTE Breast cancer - combined Stroke - >60y Cardiovascular disease - not if in WoO Endometrial cancer - unopposed oestrogen Gallbladder disease - oral oestrogen
What are risk factors for OHSS?
GnRH antagonist with HCG trigger Superovulation - raised pre-treatment follicle count Raised pre-trigger follicle count >13 over 10mm >20 collected = 2% risk Increased oestradiol Fresh embryo transfer Multiple pregnancy Prev OHSS Young Lean PCOS
What are classifications of OHSS?
MILD
Abdo distension, pain, ovary size <8cm
MODERATE
Above plus USS evidence of ascites, nausea, vomiting, diarrhoea, ovary 8-12cm
SEVERE
Clinical ascites, hydrothorax, HCT >45%, electrolyte disturbance, oliguria, Cr rise, ovary >12cm
CRITICAL
Tense ascites, large hydrothorax, HCT >55%, WCC >25, oliguria or anuria, VTE, ARDS
What are principles for management of OHSS?
Admit if severe or higher Symptom control (but avoid NSAIDs) Lower Hct Fluid balance, UO monitoring, daily weighs VTE prophylaxis Daily electrolyte checks Consider paracentesis Consider dopamine infusion Psychological support
What are the criteria for PCOS?
Chronic oligomenorrhoea or anovulation
Hyperandrogenism - clinical or biochemical
Polycystic appearing ovaries on USS
>12 as per Rotterdam
>20 as per recent criteria as USS better and would otherwise overdiagnose
AND other causes excluded
What is the pathophysiology of PCOS
Increased LH production and action
Acts on thecal cells and higher amounts of androgen production - hyperandrogenism features
Reduced insulin sensitivity and hyperinsulinaemia augments higher androgen production
- metabolic syndrome, cardiovascular disease
Hyperandrogenism leads to poor follicle maturation, cysts are follicles in arrested development - lack of dominant follicle, anovulatory cycles
Genetic contributors - as evidenced in twin studies. Autosomal dominant gene with low penetrance
Obesity contributes
Lifestyle factors
In utero hormonal exposures
What are methods of assessing tubal patency? State advantages and disadvantages.
Hysterosalpingogram
Hysterocontastsalpingography
Laparoscopic tubal dye test
What are the cause of azoospermia?
Obstructive - absent vas deferens (CF and carriers), prev infection e.g. chlamydia, vasectomy
Non-obstructive - trauma, torsion, prev mumps infection, cryptorchidism, chemotherapy, radiation therapy, medications, Kleinfelters (47 XXY), Micro-deletion Y chromosome, Hyperprolactinaemia, Kallman’s syndrome
What investigations should be carried out for azoospermia?
Clinical exam
USS – mass, varicocoele, vas deferens
STI screen
Post ejaculatory urinalysis
Testosterone, FSH, LH
PRL
- CF screen
- Karyotype – 47XXY
- Microarray – Y chromosome microdeletion
- Genetic testing should have pre-test genetic counselling
What are causes of vaginal fistulae?
*Post hysterectomy - abdominal, radical (higher risk but less common) Obstetric - obstructed labour, invasive placentation, rectal injury, iatrogenic at CS Malignancy Inflammatory - IBD, severe infection Endometriosis Foreign body erosion - pessary Radiation therapy Congenital
- Most common in developed world
Obstetric fistulae most common in developing world
Surgical management of a borderline ovarian tumor?
Stage 1 surgery
Laparoscopic
Fertility sparing if reproductive age and no invasive disease
USO (+ cystectomy if tumors bilateral)
Controversy exists whether completion surgery upon fertility completion
Full staging if no fertility desire/okay not to retain endocrine function - benefits are diagnosing more advanced stage and occult invasion
Stage 2+ Utilise frozen sections Washings TAH, BSO Omentectomy Peritoneal inspection Nodes not necessary Resection all visible disease Peritoneal biopsy Appendicectomy (mucinous)
Borderline ovarian tumors - risk factors for recurrence
Young age Higher stage Cystectomy > oophorectomy Microinvasion Invasive peritoneal implants Micropapillary pattern Serous type (as more likely to be bilateral)
What are components of vaginal discharge?
Endometrial and tubal fluid
Cervical mucous from columnar epithelium
Vaginal + cervical squamous cells (desquamated cells)
Vaginal epithelium transudate
Fluid from Bartholin’s and Skene’s glands
Normal flora - lactobacilli predominantly
What are Amsel criteria for BV?
pH >4.5
Whiff test “fishy odour” when exposed to KOH
Presence of clue cells on wet slide
Homogenous grey/white discharge coating vaginal walls
Which organisms contribute to BV?
Gardnerella vaginalis Atopobium vaginae Mobiluncus spp Prevotella spp Bacteroides Mycoplasma hominis Peptostreptococcus
List Fraser guidelines for prescribing of contraception in <16yo
May prescribe contraception as long as
- Understand advice being given, nature of treatment
- Cannot be persuaded to inform their parent/guardian
- Will commence/resume sexual activity regardless of prescription
- Physical and/or mental health is at risk without contraception or advice
- Provision of contraception is in their best interest, regardless of whether parent/guardian is informed
Rate of TOP globally
35/1000
Definition of a medically safe abortion
WHO recommended methods used by a trained operator
Risks and complications of unsafe abortions
- Higher morbidity and mortality (bleeding, infection, genital tract trauma, RPOC)
150,000 deaths occur annually worldwide due to unsafe abortion - Later presentation for problems as stigma associated with being illegal
- Care for above dependent on whether they disclose provider information
- Further costs managing complications that ensure from provision of unsafe services
- Don’t get appropriate contraception
- Higher psychological impact if illegal – also means less likely to receive appropriate counselling which could worsen mental health
