gynaecology

Question 1

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

Answer 1

Ectopic pregnancy

Question 2

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

Answer 2

Appendicitis
Ovarian torsion
Cyst rupture
Fibroid degeneration
Renal calculi

Question 3

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

Answer 3

Miscarriage

Question 4

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

Answer 4

PID
UTI
Diverticulitis
Endometriosis
Constipation
IBS
Urinary retention

Question 5

What is an ectopic pregnancy?

Answer 5

Pregnancy outwit the endometrial cavity

Question 6

Which sites do ectopic pregnancies occur?

Answer 6

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

Question 7

What are the risk factors for ectopic pregnancy?

Answer 7

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

Question 8

What is the presentation of ectopic pregnancy?

Answer 8

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

Question 9

When in pregnancy does an ectopic pregnancy usually present?

Answer 9

6-8 weeks gestation

Question 10

What investigation is diagnostic for ectopic pregnancy?

Answer 10

Transvaginal ultrasound scan

Question 11

What might be seen on ultrasound in ectopic pregnancy?

Answer 11

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)

Question 12

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

Answer 12

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

Question 13

What is a pregnancy of unknown location (PUL)?

Answer 13

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

Question 14

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

Answer 14

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

Question 15

Management of ectopic pregnancy?

Answer 15

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

Question 16

What is the criteria for expectant management of ectopic pregnancy?

Answer 16

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

Question 17

What is the criteria for medical management of ectopic pregnancy?

Answer 17

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

Question 18

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

Answer 18

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

Question 19

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

Answer 19

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

Question 20

Side effects of medical management of ectopic pregnancy?

Answer 20

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

Question 21

Which patients will require surgical management of ectopic pregnancy?

Answer 21

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

Question 22

Describe the options for surgical management of ectopic pregnancy

Answer 22

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

Question 23

What rhesus prophylaxis is needed in ectopic pregnancy?

Answer 23

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

Question 24

What is ovarian torsion?

Answer 24

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

Question 25

Risk factors for ovarian torsion?

Answer 25

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

Question 26

Pathophysiology of ovarian torsion?

Answer 26

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

Question 27

Presentation of ovarian torsion?

Answer 27

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

Question 28

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

Answer 28

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

Question 29

Investigation for definitive diagnosis of ovarian torsion?

Answer 29

Laparoscopic surgery

Question 30

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

Answer 30

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

Question 31

Complications of ovarian torsion?

Answer 31

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

Question 32

What are the types of ovarian cyst?

Answer 32

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)

Question 33

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

Answer 33

Post-menopausal women

Question 34

Which appearance of ovaries is indicative of multiple ovarian cysts?

Answer 34

String of pearls appearance

Question 35

Presentation of ovarian cysts?

Answer 35

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

Question 36

What are follicular cysts - description, prognosis, appearance?

Answer 36

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

Question 37

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

Answer 37

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

Question 38

What is a serous cystadenoma?

Answer 38

Benign tumour of epithelial cells

Question 39

What is a mutinous cystadenoma?

Answer 39

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

Question 40

What is an endometrioma?

Answer 40

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

Question 41

What is a germ cell tumour/dermoid cyst?

Answer 41

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