Gynae Emergencies

Question 1

what can cause pelvic infection?

Answer 1

PID from STIs such as chlamydia or gonorrhoea
following insertion of intrauterine devices
from organisms not sexually contracted

Question 2

risk factors associated with pelvic infection?

Answer 2

age <25
multiple sexual factors
unprotected sex
recent insertion of IUD
recent change in sexual partner

Question 3

how might pelvic infection due to PID present?

Answer 3

irregular menstrual bleeding
abnormal vaginal discharge
chronic pelvic pain
infertility

Question 4

how can ascending genital tract infection cause PID/pelvic infectoin?

Answer 4

can ascend to cause cervivitis, endometritis, salpingitis

can lead to development of tubo-ovarian abscesses

Question 5

what might help with diagnosis of pelvic infection?

Answer 5

vaginal and endocervical swabs

Question 6

signs and symptoms of pelvic infection?

Answer 6

lower abdominal pain
fever
abnormal vaginal bleeding
offensive vaginal discharge
deep dyspareuinia
dysuria or mestrual irregularities

Question 7

examination findings in pelvic infection?

Answer 7

cervical motion tenderness

adnexal tenderness

Question 8

how is pelvic infection managed?

Answer 8

if acutely unwell - manage via sepsis 6
partner notification (PID)

Question 9

empirical antibiotics in pelvic infection?

Answer 9

oral orofloxacin + metronidazole
or
IM ceftriaxone + oral doxycycline + oral metronidazole

Question 10

how are post benign ovarian cysts diagnosed?

Answer 10

presence of pelvic/abdominal mass by symptoms such as pain or incidentally on US

Question 11

how big are benign cysts usually?

Answer 11

<5cm in diameter

Question 12

how do benign ovarian cysts usually resolve?

Answer 12

spontaneously over 2-3 cycles

Question 13

how might an ovarian cyst present acutely?

Answer 13

“cyst accidents”

• haemorrhage within the cysts
• rupture of cyst
• torsion of cyst

Question 14

more long term/insidious features of ovarian cyst?

Answer 14

features of pressure on the bowel or bladder (depending on size)
can have disturbance in menstrual cycle or virilisation depending on type of cyst

Question 15

categories of causes of ovarian cysts?

Answer 15

physiological/functional
benign germ cell tumours
benign epithelial tumours
benign sex cord stromal tumours

Question 16

who does each type of ovarian cyst most commonly occur in?

Answer 16

physiological/functional = young women in reproductive years
germ cell = young women
epithelial = older women

Question 17

microscopic features of most cysts?

Answer 17

thin wall with no solid or papillary projections into the cystic cavity

Question 18

what concerning features may a cyst develop if it increases in size?

Answer 18

thick wall septa etc

Question 19

what tumour markers should be tested if cyst develops concerning features?

Answer 19

inhibin
AFP
bHCG
CA125

Question 20

other tests on concerning cyst?

Answer 20

US
CT
MRI inflammatory markers if suspicious of appendicitis or tubo-ovarian abscess

Question 21

commonest type of ovarian cyst?

Answer 21

functional

Question 22

describe functional cysts?

Answer 22

simple uniloculated cysts on US measuring >3cm

Question 23

what causes functional cyst?

Answer 23

non-rupture of dominant follicle or failure of atresia in a non-dominant follicle
usually regress after several cycles

Question 24

types of functional cyst?

Answer 24

follicular
corpus luteal
theca luteal

Question 25

management of functional cyst?

Answer 25

depends on symptoms asymptomatic = observation and repeat US to assess changes symptomatic = laparoscopic cystectomy

Question 26

most common benign ovarian tumour in women <30?

Answer 26

germ cell

Question 27

types of benign germ cell tumour?

Answer 27

dermoid cysts (mature cystic teratoma)

Question 28

describe benign germ cell tumours

Answer 28

often lined with epithelial tissue and hence may contain hair, teeth etc tend to be very big can present with torsion

Question 29

types of benign epithelial ovarian tumours?

Answer 29

``` endometrioid mucinous serous clear cell brenner ```

Question 30

where do epithelial ovarian tumours arise?

Answer 30

ovarian surface epithelium

Question 31

most common benign epithelial ovarian tumour?

Answer 31

serous cysadenoma (benign version of serous carcinoma)

Question 32

2nd most common benign epithelial ovarian tumour?

Answer 32

mucinous cystadenoma

Question 33

what problem might occur with rupture of mucinous cystadenoma?

Answer 33

pseudomyxoma peritoneii

Question 34

where are bartholin cysts/abscesses found?

Answer 34

next to entrance to vagina at 5 and 7 o clock positions

Question 35

normal size of bartholin glands?

Answer 35

pea sized | become enlarged if infected

Question 36

management of bartholin cysts/abscesses?

Answer 36

can sometimes settle with antibiotics | may require surgical procedure called marsupialization

Question 37

gynae causes of acute abdominal/pelvic pain?

Answer 37

``` ectopic pregnancy ovarian torsion ovarian cyst rupture or haemorrhage PID tubo-ovarian abscess endometriosis fibroids miscarriage mittelschmerz (ovulation pain) ```

Question 38

GI/GU causes of acute abdo/pelvic pain?

Answer 38

appendicitis diverticulitis UTI bowel obstruction

Question 39

signs and symptoms of fibroids?

Answer 39

``` can be asymptomatic menorrhagia and dysmenorrhoea lower abdo pain during menstruation subfertility pressure symptoms (urinary) bulky uterus ```

Question 40

fibroids diagnosis?

Answer 40

TV US

Question 41

management of fibroids?

Answer 41

``` 1st line = mirena (only if no uterine abnormality) mymectomy hysterectomy short term GnRH analogues uterine artery embolisation ```

Question 42

signs and symptoms of endometriosis?

Answer 42

dysmenorrhoea deep dyspareunia subfertility non-gynae signs (dysuria, urgency etc)

Question 43

diagnosis of endometriosis?

Answer 43

often via laparoscopy | tender nodularity on posterior fournix

Question 44

management of endometriosis?

Answer 44

NSAIDs and paracetamol for symptomatic relief COCP or progestogens surgery (laparoscopic excision of lesions)

Question 45

signs and symptoms of ovarian torsion?

Answer 45

sudden onset of deep colickly pain associated with vomiting and distress adnexal tenderness/acute abdomen

Question 46

US signs of ovarian torsion for diagnosis?

Answer 46

whirlpool sign on US

Question 47

management of ovarian torsion?

Answer 47

laparoscopy to untwist ovary and remove cyst | remove ovary if necrotic

Question 48

signs and symptoms of PID?

Answer 48

vaginal discharge | bilateral lower abdo pain

Question 49

diagnosis of PID?

Answer 49

FBC high vaginal or endocervical swabs pelvic imaging if needed

Question 50

when is pelvic imaging needed in PID?

Answer 50

if it doesnt settle with antibiotics | acute abdomen or palpable mass

Question 51

management of PID?

Answer 51

antibiotics | surgical drainage of abscess if present

Question 52

signs and symptoms of mittelschmerz?

Answer 52

mid cycle pain | often

Question 53

management of mittelschmerz?

Answer 53

simple analgesia and reassurance