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4th year > gynaecology > Flashcards

gynaecology Flashcards

1
Q

What is the differential for acute unilateral pelvic pain, HCG positive?

A

Ectopic pregnancy

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2
Q

What is the differential for acute unilateral pelvic pain, HCG negative with signs of infection?

A

Appendicitis
Ovarian torsion
Cyst rupture
Fibroid degeneration
Renal calculi

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3
Q

What is the differential for acute generalised pelvic pain, HCG positive?

A

Miscarriage

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4
Q

What is the differential for acute generalised pelvic pain, HCG negative with signs of infection?

A

PID
UTI
Diverticulitis
Endometriosis
Constipation
IBS
Urinary retention

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5
Q

What is an ectopic pregnancy?

A

Pregnancy outwit the endometrial cavity

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6
Q

Which sites do ectopic pregnancies occur?

A

Fallopian tubes (98%)
Cornual region (entrance to fallopian tube)
Ovary
Cervix
C-section scar

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7
Q

What are the risk factors for ectopic pregnancy?

A

Previous ectopic
Previous PID
Endometriosis
Previous surgery to fallopian tubes
IUD
Older age
Smoking

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8
Q

What is the presentation of ectopic pregnancy?

A

Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding (usually less than normal period, brown in colour)
Missed period
Lower abdominal or pelvic tenderness
Cervical motion tenderness
Shoulder tip pain, pain on defecation (caused by peritoneal bleeding)
Dizziness, fainting or syncope

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9
Q

When in pregnancy does an ectopic pregnancy usually present?

A

6-8 weeks gestation

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10
Q

What investigation is diagnostic for ectopic pregnancy?

A

Transvaginal ultrasound scan

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11
Q

What might be seen on ultrasound in ectopic pregnancy?

A

Gestational sac containing a yolk sac or fetal pole in a fallopian tube
Non-specific mass in tube - ‘blob sign’, ‘bagel sign’, ‘tubal ring sign’
Empty uterus
Fluid in the uterus which may be mistaken as a gestational sac (pseudo gestational sac)

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12
Q

How can a corpus luteum and tubal ectopic pregnancy be distinguished on ultrasound?

A

Corpus luteum will move with the ovary, where an tubal ectopic pregnancy will not

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13
Q

What is a pregnancy of unknown location (PUL)?

A

When there is a positive pregancy test and no evidence of pregnancy on the USS
Ectopic cannot be excluded and careful follow up is needed

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14
Q

How will hCG level differ in ectopic pregnancy and miscarriage from a intrauterine pregnancy?

A

In a intrauterine pregnancy the hCG will roughly double every 48 hours, this will not be the case in an ectopic or miscarriage
A rise of less than 63% over 48 hours may indicate an ectopic pregnancy
A fall of more than 50% is likely to indicate a miscarriage

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15
Q

Management of ectopic pregnancy?

A

ABCDE and resuscitate
All ectopics need to be terminated - by expectant management, medical management (methotrexate) or surgical management (salpingectomy or salpingotomy)

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16
Q

What is the criteria for expectant management of ectopic pregnancy?

A

Follow up needs to be possible
Ectopic needs to be unruptured
Adnexal mass <35mm
No visible heartbeat
No significant pain
hCG level <1500 IU/l

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17
Q

What is the criteria for medical management of ectopic pregnancy?

A

As expectant, except:
hCG level <5000 IU/l
Confirmed absence of intrauterine pregnancy on ultrasound

18
Q

How is the medical management of ectopic pregnancy administered, and why is it effective?

A

IM Methotrexate into buttock
Methotrexate is highly teratogenic - halts progress of pregnancy and results in spontaneous termination

19
Q

What advise needs to be given following medical management of ectopic pregnancy?

A

Advised not to get pregnant for 3 months following treatment due to harmful effects of methotrexate on pregnancy can last this long

20
Q

Side effects of medical management of ectopic pregnancy?

A

Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)

21
Q

Which patients will require surgical management of ectopic pregnancy?

A

Those with
Pain
Adnexal mass >35mm
Visible heartbeat
hCG levels >5000 IU/l

22
Q

Describe the options for surgical management of ectopic pregnancy

A

Laparoscopic salpingectomy - first line, removal of affected fallopian tube and ectopic pregnancy
Laparoscopic salpingotomy - may be used in women at higher risk of infertility due to damage to the other tube, cut is made in the tube, ectopic removed and tube closed, increased risk of failure

23
Q

What rhesus prophylaxis is needed in ectopic pregnancy?

A

Anti-rhesus D for rhesus negative women having surgical management of ectopic pregnancy

24
Q

What is ovarian torsion?

A

Condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube an blood supply (adnexa)

25
Q

Risk factors for ovarian torsion?

A

Ovarian masses >5cm such as cysts and tumours (present in 90% of torsion)
Normal ovaries in girls before menarche - when infundibulopelvic ligaments are longer and can twist more easily
Pregnancy
Ovarian hyperstimulation syndrome

26
Q

Pathophysiology of ovarian torsion?

A

Twisting of the adnexa and blood supply to the ovary leads to ischaemia
Necrosis and loss of function will then occur

27
Q

Presentation of ovarian torsion?

A

Sudden onset severe unilateral pelvic pain
Constant pain, progressively worse
Nausea and vomiting
(course may be milder and more prolonged)
The ovary can twist and untwist intermittently causing pain that comes and goes
Localised tenderness
May be palpable mass

28
Q

What is the initial investigation of choice for diagnosis of ovarian torsion, and what will it show?

A

Pelvic ultrasound (transvaginal preferred but not always possible)
Whirlpool sign - free fluid in pelvis and oedema of the ovary

29
Q

Investigation for definitive diagnosis of ovarian torsion?

A

Laparoscopic surgery

30
Q

Management options for ovarian torsion, and how decision is made?

A

Laparoscopic surgery for either:
detorsion - untwisting the ovary and fixing it in place
oophorectomy - removal of affected ovary
Decision is made during the surgery, based on visual inspection of the ovary

31
Q

Complications of ovarian torsion?

A

Delay in treatment can result in loss of function of the ovary
Fertility not typically affected as the other ovary can usually compensate - however infertility is possible where this is the only functioning ovary
Necrotic ovary can lead to infection, abscess, sepsis
Ovarian torsion can rupture, resulting in peritonitis and adhesions

32
Q

What are the types of ovarian cyst?

A

Physiological (functional) cysts - follicular, corpus luteum cysts
Serous cystadenoma
Mutinous cystadenoma
Endometrioma
Benign germ cell tumours/dermoid cysts
Benign sex cord stromal tumours
Complex cyst (needs investigated for malignancy)

33
Q

Are ovarian cysts more concerning for malignancy in pre, peri, or post-menopausal women?

A

Post-menopausal women

34
Q

Which appearance of ovaries is indicative of multiple ovarian cysts?

A

String of pearls appearance

35
Q

Presentation of ovarian cysts?

A

Most are asymptomatic
Pelvic pain
Bloating
Fullness in abdomen
Palpable pelvic mass
Acute pelvic pain if there is ovarian torsion, haemorrhage, or rupture of the cyst

36
Q

What are follicular cysts - description, prognosis, appearance?

A

Represent the developing follicle - when these fail to rupture and release the egg the cyst can persist
Most common ovarian cyst
Harmless and tend to disappear after a few menstrual cycles
Thin walls and no internal structures - reassuring

37
Q

What are corpus luteum cysts - description, prognosis, common cause?

A

Occur when the corpus luteum fails to break down and instead fills with fluid
May cause pelvic discomfort, pain, delayed menstruation
Often seen in early pregnancy

38
Q

What is a serous cystadenoma?

A

Benign tumour of epithelial cells

39
Q

What is a mutinous cystadenoma?

A

Benign tumour of epithelial cells - can become huge and take up lots of space in pelvis and abdomen

40
Q

What is an endometrioma?

A

Lump of endometrial tissue within the ovary, occurring in patients with endometriosis, can cause pain and disrupt ovulation

41
Q

What is a germ cell tumour/dermoid cyst?

A

Benign ovarian tumours
Teratomas meaning from the germ cells, contain various tissue types such as skin, teeth, hair, bone
Particularly associated with ovarian torsion

42
Q
A

4th year (5 decks)

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