Gynaecology Flashcards
(58 cards)
1
Q
Extra gynae questions to ask in ToP
A
Why do you want to go ahead with this?
How did you get pregnant?
How are you feeling about all of this?
2
Q
ToP investigations
A
- No examination
* Confirm pregancy (TVUSS: measure crown-rump length to get gestational age)
3
Q
ToP first trimester (<13 weeks) counselling
A
- You are x weeks pregnant
- We have medical and surgical options but medical would be best
- Mifepristone and misoprostol 24 hours apart - first one here then next at home
- Come back if vomiting within 2 hours
- Will also provide analgesia, antibiotics, pregnancy test, and STI screen to go home with
- Expect bleeding
- Pregnancy test 3 weeks later
- 5% can fail - we would offer further misoprostol or surgery
- Offer counselling
- Give leaflet with 24/7 mobile number etc.
4
Q
ToP second trimester management
A
Mifepristone given 1 hour before
- Vacuum aspiration
- Dilation, evacuation(forcepts and instruments to crush the skull) and Curettage (scrape remaining tissue)
Done under GA
Give anti-D within 72 hours
5
Q
ToP specific surgical complication
A
Asherman’s syndrome
6
Q
Post-ToP contraception
A
Mirena - stops HMB, acts locally
7
Q
Miscarriage investigations
A
Bedside, bloods, imaging approach
- Obs
- Abdominal examination - tenderness, guarding
- Speculum - cerival os, fluid
- Urine dipstick
- Urine b-hCG
• FBC, G&S (if bleeding)
- TVUSS
- Fetal doppler
8
Q
Miscarriage counselling
A
- As you know, we did some tests and scans and wanted to talk to you about what’s been going on
- Anyone you would like with you?
- Unfortunately the tests are worrying and showing that you are having a miscarriage
- This is must be really difficult to process and we are here to support you all the way
- This is not your fault
- There is info (e.g. miscarriage association document) and counselling services we can offer
- Would you like to know how we will go ahead with this?
- Medical (vaginal or oral misoprostol)/surgical
- Analgesia
- Anti-emetics
9
Q
Ectopic pregnancy investigations
A
Bedside, bloods, imaging approach
- Obs
- Abdominal examination
- Speculum
- Bimanual - cervical exciation
- Urine dip
- Urine hCG
- Bloods: FBC, U&E, LFT (Fitz-Hugh-Curtis if PID), bHCG, G&S, X-match
- TVUSS
10
Q
Ectopic pregnancy initial counselling
A
- As you know, we did some tests and scans and wanted to talk to you about what’s been going on
- Anyone you would like with you?
- Unfortunately the tests are worrying and showing that a fertilised egg has grown in one of the tubes leading to your womb, which can’t develop any further into a complete pregnancy
- Are you okay to continue?
- We call this an ectopic pregnancy and it is not possible to save this pregnancy
- Worried about your health if this continues so we advise removing the pregnancy tissue
11
Q
Ectopic expectant counselling
A
Low risk, haem stable, asymptomatic, decreasing bHCG
• Pregnancy tissue will dissolve by itself
• Regular blood tests to check hCG
• Some vaginal bleeding - use pads or towels
• Paracetamol for tummy pain
12
Q
Ectopic medical management
A
- Methotrexate injection
- Regular blood tests
- If this doesn’t work - second dose or surgery
- May feel tummy pain, dizzy, nausea etc.
- Use contraception for at least 3 months after treatment as methotrexate can be harmful for baby if you become pregnant again
- Avoid alcohol as methotrexate can damage your liver
13
Q
Ectopic surgical management
A
Surgery done if ruptured or haem unstable
- Keyhole surgery - thin viewing tube and small surgical instruments inserted through incisions
- Given anaesthetic
- If the other fallopian tube looks healthy, the entire fallopian tube with the pregnancy tissue will be removed
- Should be able to leave few days after surgery
• Offer counselling services
14
Q
bHCG changes in early pregnancy
A
Rise of over 66% over 48 hours
15
Q
Ectopic pregnancy risk factors
A
- PID
- Assisted conception
- Pelvic surgery
- Previous ectopic
- Smoking
- IUD
16
Q
Molar pregnancy investigations
A
Bedside, bloods, imaging approach
• Pregnancy test
• Speculum
• Bimanual - no uterine or adnexal tenderness
- Serum hCG
- TVUSS - snowstorm/bunch of grapes
17
Q
Molar pregnancy counselling
A
- As you know, we did some tests and scans and wanted to talk to you about what’s been going on
- Anyone you would like with you?
- Unfortunately the tests are worrying and show that you have a non-viable pregnancy, which means that this pregnancy does not have a chance of a baby being born
- Are you okay to continue?
- Not your fault and nothing you have done has caused this
- Sperm and egg haven’t fused properly
- Abnormal cells can grow as it’s stimulated by hormones
- Growth can damage the reproductive organs so best to remove it
- Done under GA using a small tube and suction
- Doesn’t affect future chance of getting pregnant, but can increase the risk of having another molar pregnancy so have to monitor
- Pregnancy test 3 weeks later
- Trophoblastic screening centre follow-up 6 months later
- Use barrier contraception until follow-up
18
Q
Molar pregnancy management
A
- Ripen with prostaglandins
- May give methotrexate (+ folinic acid)
- Suction curretage
- Send for histology
- Anti-D if needed
• Pregnancy test 3 weeks later
19
Q
Partial vs complete mole
A
Partial - empty egg fertilised by 2 sperm (abnormal foetal parts)
Complete - normal egg fertilised by 2 sperm (no foetal parts)
20
Q
Subfertility investigations
A
Hormones
• Early follicular phase FSH, LH, oestradiol (day 2-3)
• Anti-Mullerian hormone (ovarian reserve)
• Mid-luteal progesterone (7 day before end)
• TFTs, prolactin, and testosterone if irregular cycle
STI screen
• HIB, hep B, hep C if assisted reproductive technology
TVUSS
• Antral follicle count (<4 = poor)
• Identify pathology
Tubal assessment
• Hysterosalpingography if risk factors for tubal damage e.g. PID
Semen analysis
• 2 tests 3 months apart
21
Q
Subfertility management
A
Ovulation induction - clomiphene or FSH Intrauterine insemination (mild endometriosis) Donor insemination IVF Donor egg with IVF Surgical management (pathology)
22
Q
Subertility initial counselling
A
- RF contribute (age, smoking, obesity, irregular periods, STI)
- Chance of getting pregnant naturally
- Start investigations
- Encourage regular unprotected sex every other day
- Management options depend on cause of subfertility
23
Q
PCOS investigations
A
Bedside, bloods, imaging approach • Obs • Inspection - hirsutism, acne • BMI • Abdo examination • Pregnancy test
- Progesterone, prolactin, TSH, testosterone
- Lipid panel
- OGTT
• TVUSS
Rotterdam criteria
• Oligo/anovulation > 2 years
• Clinical/biochemical features of hyperangrogenism
• Polycystic ovaries (>=12)
24
Q
PCOS management
A
Approach different aspects of the condition
Lifestyle
• Weight reduction if overweight
• Diet modification and exercise if increased risk of T2DM and CVD
Hirsutism and acne
• COCP/Co-cyprindiol
• Topical eflornithine cream
Infertility
- Clomifene
- Metformin
- Gonadotrophins
25
Menopause investigations
* Pregnancy test
* PHQ-9
* BMI
• FBC, TSH
(dependent on symptoms)
26
Menopause management
Lifestyle
• Weight loss
• Avoid alcohol and caffeine
• Wear layered clothing, use hand-held fans
Hormonal
• Oestrogen with progesterone (to protect endometrium), cyclical (progesterone for last 14 days to get withdrawal bleed) or continuous
• Oestrogen alone (IUS or if had hysterectomy, transdermal if BMI>30)
```
Non-hormonal
• Clonidine (alpha agonist - for hot flushes)
• Beta-blockers (for palpitations)
• Lubricants
• Psychological - self-help, CBT, SSRIs
```
Keep up to date with breast and cervical cancer screening, support groups
27
HRT benefits and risks
Benefits
• Improved symptoms
• Osteoporosis prevention
Risks
• Oestrogen - endometrial cancer, breast tenderness, nausea, headaches
• Progestogen - breast cancer, VTE, fluid retention, mood swings
• Stroke, IHD
28
VV candidiasis investigations
Bedside investigations
* Consider obs (fever for example if worried about other infections)
* Examination of external genitalia - vulval erythema, fissuring
* Speculum - cottage cheese, non-offensive discharge
* High vaginal swab - yeast cells and pseudohyphae
* Pregnancy test - can't take oral antifungals
* MSU dipstick
29
VV candidiasis counselling
* Fungal infection and inflammation of the vulval area
* Could happe because x can disturb the balance of bacteria in the vagina so too much yeast can grow
* Very common and may occur again
* Not an STI but increased
* Give you one dose of 150mg fluconazole, can be bought OTC
* Use simple emollients to wash, don't douche or use harsh soaps
* Avoid tight-fitting clothes
* Come back if it doesn't improve in the next couple of weeks
* Otherwise follow-up not needed
30
PID investigations
```
Bedside, bloods, imaging approach
• Obs
• Pregnancy test
• Urine dipstick
• Speculum
• Bimanual
• Endocervical swab - wet mount and culture for Chlamydia and Gonorrhoea, NAAT for Mycoplasma genitalium
```
* FBC, CRP
* TVUSS
31
PID initial management
Assess whether seriously unwell and needing admission
Remove IUD if present
Abx
• Ceftriaxone (IM single)
• Doxycycline (BD oral 14 days)
• Metronidazole (BD oral 14 days)
32
PID counselling
* Infection has spread up to the uterus
* Risk of infertility, ectopic, chronic pelvic pain
* Treat with antibiotics - 1 injection and 2 tablets
* Do not have sex until course complete
* Full STI screen and encourage contact tracing
* Dicuss contraception
• Follow up in 3 days (assess response, if none then IV abx) and 2-4 weeks (ensure resolution, counsel on STIs, check fertility)
33
Incontinence investigations
* Obs (UTI)
* Urine dip (UTI)
* BMI
* Pelvic exam if worried about prolapse
* Bladder diary
* Cystoscopy
* Urodynamics if considering surgical mx
34
Incontinence lifestyle management
* Reduce caffeine
* Modify fluid intake
* Lose weight if BMI>30
* Stop smoking
35
Stress incontinence management
* Lifestyle
* Pelvic floor exercises (8c,tds,3m)
* Colposuspension
* Synthetic mid-urethral tape
• Duloxetine - SNRI (stimulates urethral sphincter)
36
Urge incontinence management
* Lifestyle
* Bladder retraining (5 weeks)
* Antimuscarinics (oxybutinin, solifenacin)
* B3 adrenoreceptor agonist (mirabegron)
* Bot. toxin A every 6 months
* Percutaneous sacral nerve stimulation (12x sessions every week)
* Augmentation cystoplasty
* Reconstructive surgery
37
Pelvic organ prolapse examinations
Abdo exam
Pelvic exam and speculum:
• POP-Q quantification system (assesses presence and degree of prolapse using clinical findings)
• Assess activity of pelvic floor muscle
• Assess for vaginal atrophy
• Rule out other pathology i.e. pelvic mass
BMI
38
Pelvic organ prolapse management
* Weight loss if BMI >30
* Minimise heavy lifting
* Treat constipation
* Vaginal oestrogen if atrophy
* 16 weeks pelvic physiotherapy
* Vaginal ring pessary
* Sacro-hysteropexy with mesh
* Vaginal hysterectomy
39
Extra prolapse hx questions
* Worse at end of day?
* Sexually active - affected?
* Lifting heavy objects?
40
Bartholin's cyst investigations
* Obs (temperature)
* Inspection - unilateral tender erythematous swelling, posterolateral of introitus
* Speculum/bimanual - uslally too tender (ddx STI, Behcet's, other abscess)
41
Bartholin's cyst management
Asymptomatic
• conservative, sitz baths/warm compress to aid drainage
Symptomatic
• Small - conservative and abx
• Large - refer for emergency drainage and marsupialisation (edges sewn with dissolvable suture)
* Analgesia
* Broad-spectrum abx cover
* Recommend STI screen
42
Endometriosis investigations
Bedside, bloods, imaging approach
• Abdominal exam - suprapubic tenderness, adnexal mass, fixed uterus
• Bimanual - reduced organ mobility, tender nodularity
• Urine dipstick
• Pregnancy test
• Cervical swab
• FBC, U&E, bhCG
* TVUSS
* Endorectal USS (deep pelvic disease)
43
Endometriosis management
MDT involved: GP, O&G, support groups, psychosexual counselling
1. NSAIDs/paracetamol
2. COCP or progesterone hormonal (6 months, suppress HPO axis)
3. GnRH analogue (suppress HPO axis) + HRT (osteoporosis risk), can be given prior to surgery 3/12
4. Surgery - laparoscopic excision
5. Total abdominal hysterectomy and bilateral salping-oophorectomy
44
Endometriosis ddx
* Adenomyosis
* PID
* IBS
45
UKMEC4
```
>35 smoking >15/day
Migrain with aura
Thromboembolic hx/mutation
Stroke or IHD hx
Breast feeding <6 weeks pp
Uncontrolled HTN
Current breast cancer
Major surgery + immobilised
Antiphospholipid ab (e.g. SLE)
```
46
Fibroids investigations
Bedside, bloods, imaging approach
• Pregnancy test
• Abdominal exam
• Bimanual exam - enlarged, firm, smooth uterus
* FBC
* TVUSS
47
Fibroids counselling (preserve fertility) and intramural + subserosal (no fertility needed)
* From your history, tests and scans, it looks like you have something called a fibroid, is this something you've heard about before?
* Common, non-cancerous growth of the womb
* No symptoms in a lot of people, but can cause HMB, pain, and difficulties getting pregnant
If medical - NSAIDs and tranexamic acid
Myomectomy recommended
• Small incisions in your tummy, called a keyhole surgery under GA (open myomectomy if >10cm)
• You will need to stay in hospital for a couple of days and advised to rest for a few weeks after
• Usually effective, chance it could grow back
Intramural + subserosal (no fertility)
• Add IUS / COCP
• Could consider hysterectomy
48
Submucosal fibroids counselling (not wanting to become pregnant)
Transcervical (hysteroscopic) resection of fibroid (TCRF)
• Thin tube + small surgical instruments used
• Inserted through vagina into the womb to remove fibroid tissue
• Under GA
• Go home the same day
* Expect stomach cramps and some vaginal bleeding after
* Consider iron supplements to help IDA
• Could consider hysterectomy
49
Medical term for fibroid, treatment for asymptomatic fibroid, and complication in pregnancy
Leiomyoma
Monitor size
Red degeneration
50
Cervical cancer investigations
* Speculum
* Smear
* STI screen
* Pregnancy test
2ww referral
51
CIN1,2,3 management
CIN1 - repeat smear in 1 year
CIN2,3 - LLETZ* or cone biopsy, repeat smear in 6 months
*Large loop excision of transformation zone
Risk of mid-trimester loss of preterm birth with surgical management
52
Endometrial cancer investigations
* Abdo exam
* Speculum
* Bimanual
* Pregnancy test
2ww referral
• TVUSS (endometrium > 4mm)
• Hysteroscopy and biopsy
53
Endometrial cancer investigation counselling
* PMB caused by many things, a lot of which are harmless like trauma and infection
* Priority to rule out cancer
* TVUSS - explain
* Based on result, establish diagnosis and start treatment accordingly
* Further testing may be needed depending on scan results
54
Endometrial cancer management
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
* Post-op radiotherapy if high risk
* Progesterone therapy (IUS) if frail and unfit for surgery
55
Ovarian cancer investigations
```
Beside, bloods, imaging approach
• Abdo exam
• Speculum
• Bimanual
• Pregnancy test
```
* CA-125
* TVUSS
56
Ovarian cancer management
Total hysterectomy with bilateral salpingo-oophorectomy +/- chemo
If fertility needs to be preserved, only remove affected ovary
57
Vulval cancer initial investigations
* Abdo exam
* Vulval inspection and examination
* Skin swab
* Urine dip
* Pregnancy test
58
Vulval cancer counselling for next steps
* Further test involving 2ww
* Biopsy to check sample under microscope
* Once confirmed, treatment may include surgery, radiotherapy and chemotheapy depending on stage
* Even though rare cancer, specialists have seen many cases
* Smoking cessation as smoking can slow down recovery
