Gynaecology - Management Flashcards

Question

Surgical management of fibroids Indications + types of surgery

Answer 1

Surgical Indicated when • There is excessively enlarged uterine size • Pressure symptoms are present • Medical management is not sufficient to control symptoms • The fibroid is submucous and fertility is reduced • Myomecotmy o Safe alternative to hysterectomy o Open or laparoscopic o Power morcellation used to shrink the fibroids for removal o Maintains reproductive potential/keeps uterus o Laparoscopic myomectomy – subserous fibroids o Hysteroscopic myomectomy – submucosal fibroids • Vaginal removal of pendunculated vaginal fibroids – if >60, histology to exclude sarcoma • Hysteroscopic TCRF (transcervical removal of fibroids) o Small submucosal or polypoid fibroids • Hysteroscopic endometrial ablation o Women presenting with menorrhagia • Total hysterectomy o In women who have completed their family – hysterectomy remains the most effective treatment for excessive uterine bleeding o In women with many fibroids o Small fibroids – vaginal route o Large fibroids, intraligamentous fibroids – laparotomy with preservation of ovaries o Laparoscopic hysterectomy – higher risk of urinary tract injury + severe bleeding in comparison to open surgery o Risk of blood loss directly related to uterine size – reduced by pre-treatment with GnRH agonists • Uterine artery embolization (UAE) o Effective and safe for women who wish to keep their uterus o May preserve fertility, may also make ovaries fail o Embolise both uterine arteries – infarct/degenerate fibroids o Patients need admission to deal with associate pain (opiate analgesia) • MRI-guided transcutaneous focused US o Low morbidity, rapid recovery o High-power US are used to ablate the fibroid – there may be skin burns as a result

Answer 2

Myomectomy o Risk of  Excessive bleeding – cross match blood  Requiring hysterectomy at the time of operation –obtain consent for hysterectomy  C-section in the future – risk of uterine rupture Uterine artery embolization o Risk of  Fever, infection, fibroid expulsion, potential ovarian failure  Placental insufficiency – small-for-gestational-age babies, increased c-section, prematurity  May necessitate hysterectomy due to complications during procedure – consent beforehand o As effective as myomectomy for alleviating fibroid DUB and pressure symptoms

Answer 3

• Management – reassurance o Generally advised to remove (twist off if small or surgery) o Polypectomy for symptomatic and large (>3cm) endocervical polyps o To destroy the base of the polyp – liquid nitrogen, electrocautery ablation, laser surgery o For more persistent lesions – surgical dilatation and curettage, electrosurgical excision, hysteroscopic polypectomy o Send for histology

Answer 4

Reassurance Cauterisation - burn + remove Cryotherapy - freeze + remove Move from oestrogen-based contraceptives

Answer 5

o May resolve spontaneously if small o Premenopausal – polypectomy for polyps >1.5 cm/symptomatic polyps/prolapsed polyps/multiple polyps/polyps associated with infertility o Postmenopausal – polypectomy or hysterectomy o Hysteroscopic removal or morcellation o Polypectomy to (day case under GA or OPD under LA) Alleviate AUB (abnormal uterine bleeding) symptoms Optimise fertility Exclude hyperplasia/cancer

Answer 6

Healthy lifestyle – 1st line • Smoking cessation, lose weight, limit alcohol + caffeine, regular aerobic exercise • Adequate calcium intake (around 700 mg/day) • Hot flushes – regular exercise, WL, reduce stress • Sleep disturbance – sleep hygiene, no late evening exercise o Mood – sleep hygiene, regular exercise, relaxation techniques o Cognitive symptoms – sleep hygiene, regular exercise

Answer 7

Oestrogen (Elleste Solo) to women without a uterus • OD, oral oestrogen – standard therapy Oestrogen + progestogen (Elleste duet) to women with a uterus • Progesterone protects the endometrium • You can have an oestrogen only preparation combined with an LNG-IUS (Mirena coil, releases progesterone) o Progesterone – oral progesterone, mirena (better at protecting uterus) o Topical oestrogen – vagifem, ovestin o oestrogen patches

Answer 8

Pattern of HRT • Peri menopausal - Cyclical/Sequential pattern (SCT) o Monthly:  Oestrogen every day of the month + progesterone the last 14 days  Produces a bleed every month  Indication – Regular periods + menopause symptoms o 3-monthly  Oestrogen every day + progesterone alongside if for around 14 days every 3 months  Indication – irregular periods + menopause symptoms  Produces a bleed every 3 months  Common cause of IMB = endometrial polyp • Post-menopausal (no period for >1 year) - Continuous pattern (CCT) o Oestrogen + progesterone every day

Answer 9

* Oestrogenic – breast tenderness, nausea, headaches * Progestogenic – fluid retention, mood swings, depression ``` • Unscheduled vaginal bleeding o Common in the first 3 months of HRT o Sequential>continuous HRT o Investigate if it continues past 6 months or after a spell of amenorrhoea) ```

Answer 10

* Any oestrogen-sensitive cancer * Current or past Breast cancer * Untreated endometrial hyperplasia * Undiagnosed vaginal bleeding * Hx of VTE * Current thrombophilia (AT-III, FV Leiden) * Severe liver disease * Pregnancy

Answer 11

• Improved menopause symptoms - Most effective treatment to relieve the symptoms caused by menopause completely, particularly o Vasomotor symptoms (hot flushes/night sweats) o Mood swings o Vaginal + bladder symptoms • Osteoporosis o Risk of fragility fracture is decreased while taking HRT  Fragility fracture – fracturs that result from mechanical forces that would not ordinarily result in fracture (fall from a standing height or less)  Most commonly occur in the spine, hip, wrist  Reduced BMD is a major RF o This benefit is maintained during treatment but decreases once treatment stops o This benefit may continue for longer in women who take HRT for longer • Cardiovascular disease o Oral (but not transdermal) oestrogen associated with a small increase in the risk of stroke o HRT oestrogen alone associated with no/reduced risk of CHD o HRT oestrogen + progestogen associated with no/little increase in the risk of CHD

Answer 12

• Cancer o Oestrogen only – endometrial cancer, ovarian o Combined – breast cancer, ovarian o Any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT • VTE o Risk increased by oral HRT (oral>transdermal) o Risk of VTE associated with transdermal no greater than baseline population risk o Consider transdermal HRT for menopausal women who are at increased risk of VTE, incl. those with BMI >30kg/m2

Answer 13

Managing short-term menopausal symptoms and alternative therapies to HRT • The recommendations in this section are not intended for women with premature ovarian insufficiency (POI) • Vasomotor symptoms o HRT o Do not routinely offer SSRI or SNRI or clonidine as first-line treatment for vasomotor symptoms alone unless HRT cannot be given o SSRIs – fluoxetine, paroxetine, sertraline, citalopram  Paroxetine is the most effective  Women on tamoxifen should not take fluoxetine or paroxetine  makes tamoxifen ineffective o SSRI-SNRIs – venlaflaxine  Velnaflaxine preferred in people taking Tamoxifen  Improvement in fatigue, mental health, sleep disturbance o SSRI + SNRI SE – dry mouth, nausea, constipation, appetite problems, reduction in libido o Alpha agonists – clonidine  Licenced but there are lots of anti-Ach SE  Only non-hormonal drug licensed for use for hot flushes in the UK  25 mcg BD for 2/52, increased to a max of 50 mcg TDS  Must be withdrawn gradually – suddenly stopping it can cause rebound high blood pressure  Anti-hypertensive – therefore not suitable for patients with low BP o Gabapentin  Improves flushes and sweats  SE – sleepiness, dizziness, weight gain, dry mouth o Vasomotor symptoms – isoflavines, black cohoshm clonidine, evening primrose oil, black cohosh, magnesium, st johns wort, acupuncture  Multiple preparations are available and their safety is uncertain  Different preparations may vary  Do not know which doses are effective  Interactions with other medicines have been reported  Not recommended for breast cancer survivors  Women on tamoxifen should not take St. John’s wort  makes tamoxifen ineffectieve • Psychological symptoms o HRT – low mood o CBT – low mood + anxiety o No clear evidence for SSRIs or SNRIs • Altered sexual function o Testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective o Tibolone • Urogenital atrophy o Vaginal oestrogen (also offered to those on systemic HRT) o Moisturisers and lubricants can be used alone or in addition to vaginal oestrogen o Vaginal lubricants Effective to use as non-hormone alternatives esp. if the main symptoms are pain on intercourse due to dryness o Topical HRT in the short-term treatment of menopausal atrophic vaginitis * Vaginal dryness – lubricants * Osteoporosis treatment – tibolone, bisphosphonates (alendronic acid, ibandronic acid, risedroni acid, zoledronic acid), calcium, vitamin D, raloxifene (approved for prevention and treatment of osteoporosis in postmenopausal women and to reduce risk of invasive breast cancer in postmenopausal women at high risk or with osteoporosis) • Herbal or complementary treatments o Phyto-oestrogens  Naturally occurring compounds found in plant sources  Structurally related to estradiol  Isoflavins, genistein, daidzein, glycitein, ligans, coumestans  Soy beans, nuts, wholegrain cereals, oilseeds  Can be taken in the form of tablets  Efficacy has not been proven in RCTs, meta-analysis has shown that their use is associated with a reduction in the frequency of hot flushes

Answer 14

Early menopause management • HRT continued until they reach 51 years unless contra-indicated • May need larger doses of HRT to control vasomotor symptoms o Symptoms may be more severe in premature menopause, particularly after surgical menopause, often requiring higher doses of oestrogen than those needed following spontaneous menopause at a later age • There is no evidence that there is any increased risk of breast cancer compared with normally menstruating women of the same age for early menopausal women on HRT

Answer 15

Premature ovarian insufficiency POI management • Sex steroid replacement + HRT or COCP (combined hormonal contraceptive) o Unless contraindicated (for example, in women with hormone-sensitive cancer) o HRT/COCP should be continued until at least the age of natural menopause o HRT may have a beneficial effect on blood pressure when compared to the COCP o Both HRT + COCP offer bone protection o HRT is not a contraceptive

Answer 16

 Oral/depot Medroxyprogesterone acetate  Dienogest  Cyproterone acetate  Norethisterone acetate

Answer 17

``` leuprorelin nafarelin buserelin goserelin triptorelin ```

Answer 18

Hormonal treatment after surgery • Short-term (<6 months)  not recommended as there is no evidence that it improves the outcomes of the surgery • Long-term (>6 months)  contraception, secondary prevention o LNG-IUS o COCP o Indication: secondary prevention of endometriosis associated dysmenorrhoea but not for non-menstrual pelvic pain or dyspareunia

Answer 19

• In infertile women with endometriosis clinicians should nor prescribe hormonal treatment for suppression of ovarian function to improve fertility • AFS/ASRM stage I/II o Operative laparotomy – excision or ablation of the endometriosis lesions incl. adhesiolysis rather than diagnostic laparoscopy only – Increases ongoing pregnancy rates o CO2 laser vaporisation of endometriosis o Intrauterine insemination with controlled ovarian stimulation within 6 months after surgical treatment – increases live birth rates compared to expectant mx • Ovarian endometrioma o Excision of the endometrioma capsule + electrocoagulation of the endometrioma wall o risks of reduced ovarian function after surgery + possible loss of ovary o If endometrioma >3cm  No evidence that cystectomy prior to treatment with assisted reproductive technologies improves pregnancy rates  Only consider cystectomy to improve endometriosis-associated pain or the accessibility of follicles • AFS/ASRM stage III/IV o Can consider operative laparoscopy instead of expectant management to increase spontaneous pregnancy rates • Do not prescribe adjunctive hormonal treatment before/after surgery to improve spontaneous pregnancy rates • Use of assisted reproductive technologies for infertility associated with endometriosis, especially if tubal function is compromised or if there is male factor infertility, and/or other treatments have failed o GnRH agonists for a period of 3 to 6 months prior to treatment with assisted reproductive technologies – improves clinical pregnancy rates in infertile women with endometriosis o If undergoing laparoscopy prior to treatment with assisted reproductive technologies  complete surgical removal of endometriosis

Answer 20

• Surgically induced menopause because of endometriosis  estrogen/progestogen or tibolone for at least up to the age of natural menopause • Postmenopausal women after hysterectomy + a hx of endometriosis  avoid unopposed estrogen o Endometriosis is an oestrogen-depending confition o Hormonal therapy in women with menopausal symptoms + a hx of endometriosis may reactivate residual disease or produce new lesins o Balance risk of disease reactivation + malignant transformation of residual disease against the increased systemic risks with combined oestrogen/progestogen or tibolone

Answer 21

* The first “bleed-free” HRT contains a synthetic hormone known as Tibolone, which is taken orally every day * Combined oestrogen, progestogen and testosterone effects * Relieves menopausal symptoms, prevents bone loss, and may improve interest in sex * Normally prescribed at least 12 months after the last menstrual period, so many women switch to these continuous types after taking a sequential HRT * Has also been shown to be particularly useful in women who are known to have endometriosis and fibroids as it does not appear to stimulate these conditions

Answer 22

* Tamoxifen is extensively metabolised via cytochrome P450 2D6 (CYP2D6) to active metabolites, the most significant of which is endoxifen. * Paroxetine is a potent CYP2D6 inhibitor, * Fluoxetine is a moderate-to-potent inhibitor, and fluvoxamine and duloxetine are moderate inhibitors. * Preference should be given to SSRIs/SNRIs with weak inhibitory effects on CYP2D6, such as citalopram, escitalopram, sertraline and venlafaxine  Women on tamoxifen should not take fluoxetine or paroxetine  makes tamoxifen ineffective  Velnaflaxine preferred in people taking Tamoxifen

Answer 23

Treatments for breast cancer survivors • Most clinical guidelines do not recommend oestrogen based treatments • NAMS (north American menopause society)  SSRIs, SNRIs, gabapentin, pregabalin, clonidine, CBT • UK NICE o SSRIs, SNRIs, Gabapentine – no better than placebo o Paroxetine + fluoxetine – will reduce the efficacy of tamoxifen o Clonidine, venlafaxine, gabapentine o St Johns wort may improve symptoms but not recommended because of serious drug interactions • Isoflavones, red clover, black cohosh – not recommended

Answer 24

``` Hormonal preparations (oestrogen): Topical and systemic oestrogens are the most efficacious treatment for atrophic vaginitis ``` • Topical HRT o Restores vaginal pH o Works by thickening and revascularizing the vaginal epithelium, so improving lubrication o Helps to improve urinary symptoms o Systemic HRT – not recommended as 1st line treatment for those with only vaginal symptoms + no menopausal symptoms o Around 10-25% of women receiving HRT still have symptoms – will require topical oestrogen in addition to HRT • Topical treatments: o Intravaginal cream  Common to have more vaginal discharge with creams  This may be an advantageous SE in sexually active women o Vaginal gel o Vaginal tablets o Vaginal pessary  One vaginal pessary daily for the first 3 weeks  Reducing to one vaginal pessary 2ice a week o Vaginal ring  Inserted into the upper third of the vagina  Changed every 3 months  Maximum duration of continuous treatment = 2 years Vaginal oestrogens can be really effective in patients with urinary symptoms No evidence that topical oestrogens cause endometrial proliferation after long-term use Low dose topical oestrogen is safe and does not need to be given with systemic progestogens Women receiving hormonal treatment should be advised to contact their doctor if they experience any vaginal bleeding Non-hormonal treatments Lubricants + moisturisers used in those with contra-indications/cannot use oestrogen Lower efficacy than oestrogen • Lubricants • Moisturisers o Bio-adhesive – attach to mucin and epithelial cells on the vaginal wall – therefore retain water o Can also lower vaginal pH o Safe to be used daily o Should be used regularly rather than during sexual intercourse + systemic HRT If co-existent menopausal sx

Answer 25

• Surgical management o Hysteroscopic adhesiolysis (sometimes assisted by laparoscopy) – to cut the adhesions of the uterine wall • Post-op management – re-adhesion prevention o Chemicals  Hyaluronic acid – acts as a temporary barrier to prevent re-adhesion and may also promote tissue repair o Splint/balloon insertion to prevent apposition of the walls during the immediate post-operative healing phase o Weekly in-office hysteroscopy to cut away any newly formed adhesions o Paediatric Foley catheter  To separate the uterine walls to prevent the recurrent adhesions  Insert into the uterine cavity for 5-7 days with a bag removing the drainage of the uterus • Uterus restoration therapies o Oestrogen supplementation  Can be inserted into the uterus as post-op ICUD for 2-3 months – oestrogens induce endometrial proliferation + prevent re-formation of IUA  Repairs + restores the uterine wall, stimulates uterine healing  2 cycles of cyclical oestrogen + progesterone (Specialties guide) o Antibiotics – to prevent infections + inflammation that may damage the uterus and trigger re-adhesion of the uterine walls * Mild cases – only require surgical treatment * Severe cases – may require all 3 approaches

Answer 26

• Prevention o Misoprostol for miscarriage or RCT o Perform D+C under US guidance rather than blindly o Early identification of miscarriage – adhesions are more likely to occur after a D+C the longer the period after fetal death

Answer 27

>6 weeks pregnant --> EPAU referral • Threatened miscarriage – expectant management o Advise a woman with vaginal bleeding + confirmed intrauterine pregnancy with a fetal heartbeat that  If her bleeding gets worse or persists beyond 14 days she should return for further assessment  If the bleeding stops, she should start or continue routine antenatal care  Offer vaginal micronized progesterone 400mg BD to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and a previous miscarriage  If a fetal heart beat is confirmed, continue progesterone until 16 completed weeks of pregnancy * Complete miscarriage – menstruation will begin in 4-8 weeks, try for another when mentally ready * Incomplete miscarriage – expectant for 14 days (1st line) , medical or surgical (2nd line)

Answer 28

<6 weeks pregnant - expectant management, no USS • Pregnancy test in 1 week • If positive/symptoms persist – follow up in clinic in 2 weeks • If RPC – medical/surgical mx

Answer 29

RMC • Low dose aspirin + LMWH if thrombophilia identified (APLS) APLS • Symptoms – VTE, arterial thrombosis, thrombocytopenia, RMC, pre-eclampsia o Assess for features of SLE • Ix – lupus anticoagulant AB +/- anti-cardiolipin Ab • Mx o Acute – warfarin + LMWH o Chronic – DOAC o Pregnancy – low-dose aspirin + LMWH

Answer 30

Conservative/Expectant for confirmed miscarriage (70%) • 1st line treatment - expectant management for 7 to 14 days for women with a confirmed dx of first-trimester miscarriage after the scan at the EPAU o Expectant management for 7-14 days o Urine pregnancy test after 3 weeks  If positive – need to be reviewed and considered for either medical or surgical treatment o Review the condition of the woman at a minimum 14 days after the first follow-up appointment • Repeat scan after the period of expectant management if the pain and the bleeding o Have not started (suggesting that the process of miscarriage has not begun) or o Are persisting and/or increasing (suggesting incomplete miscarriage) – follow up in clinic in 4 weeks • Consider other management options (medical or surgical) in women with o An increased risk of haemorrhage (e.g. she is in the late first trimester) o A previous adverse or traumatic experience associate with pregnancy (stillbirth, miscarriage, antepartum haemorrhage) o Increased risk from the effects of haemorrhage (if she has coagulopathies or is unable to have a blood transfusion) o Any evidence of infection * Offer medical management to women with a confirmed dx of miscarriage if expectant management is not acceptable to the woman * Conservative management is associated with higher unplanned emergency interventions + blood transfusion rates but no difference in infection rates

Answer 31

Medical management of confirmed miscarriage (20-30%) • 2nd line – expectant failed, pt choice o If bleeding has not started within 24h of treatment, contact a healthcare professional • Misoprostol o Synthetic prostaglandin analogue – binds to myometrial cells to cause cervical softening + dilation + uterine contractions leading to expulsion of tissue o Vaginal - Missed (800μg, single dose) or incomplete (600 μg, single dose) miscarriage o Oral - alternative o Pessary is the most effective, oral tablets are the least effective • Can cause more pain and bleeding than surgical o Bleeding can continue for up to 3 weeks * Analgesia * Anti-emetics • Mifepristone no longer given • Women should take a urine pregnancy test 3 weeks after the medical management of miscarriage o If worsening symptoms/positive urine test after 3 weeks – return to review that there is no molar or ectopic pregnancy

Answer 32

* If medical failed, pt choice * Less likely than medical management to lead to emergency intervention, associated with a shorter duration of bleeding + fewer GI SE – no difference in infection rates or need for transfusion ``` • Clinical indications for surgical mx o Persistent excessive bleeding o Haemodynamic instability o Evidence of infected retained tissue o Suspected gestational trophoblastic disease ``` • Choice of o Manual vacuum aspiration (suction curettage) under LA in an OP or clinic setting  Safe, Quick, less painful than sharp curettage  Sexual hx/screening for infection (incl. Chlamydia trachomatis) should be undertaken in women undergoing surgical uterine evacuation o Surgical management in theatre, under GA  ERPC – evacuation of retained products of conception * Vaginal or sublingual misoprostol is often used to ripen the cervix to facilitate cervical dilation for suction insertion * Anti-rhesus D prophylaxis (250IU) NICE: o Should be offered to all rhesus -ve women who have had a surgical procedure to manage a miscarriage o Do not offer anti-rhesus D prophylaxis to women who  Receive solely medical treatment for their ectopic pregnancy or miscarriage or  Threatened/complete miscarriage or  PUL BCSH o Administer if mother is rhesus -ve + >12w GA (any method of management) o Therapeutic termination - anti-D given regardless of method + GA • Tissue obtained at the time of miscarriage is examined histologically – confirm pregnancy + exclude ectopic pregnancy or gestational trophoblastic disease

Answer 33

Advice • There is no evidence to support couple delaying attempts to conceive following a miscarriage * Conservative/expectant management – should perform a pregnancy test 3/52 after resolution of bleeding + pain * Medical management – Should perform a pregnancy test 3/52 after receiving medical management unless they have worsening symptoms o Worsening symptoms – review, may need a repeat USS - ?molar or ectopic pregnancy, * Smoking, alcohol, illicit drug use * Vitamin supplementation prior to or in early pregnancy does not prevent miscarriage although multivitamins with iron and folic acid do reduce the risk of stillbirth

Answer 34

* Expectant management – higher risk of incomplete miscarriage, need for unplanned/additional surgical emptying of the uterus, bleeding and need for transfusion * Surgery – uterine perforation, cervical tears, intraabdominal trauma, intrauterine adhesions, haemorrhage, retained products of conception, infection • After complete miscarriage, bleeding stops within 10 days o If part of the placenta remains – bleeding may continue with cramps o Repeat USS + surgery often required

Answer 35

o Suction curettage  Method of choice of evacuation for complete and partial molar pregnancies  US guidance during removal and curettage - minimise the chance of perforation and to ensure that as much tissue as possible is removed o Urinary pregnancy test  To be performed 3 weeks after medical management of failed pregnancy if products of conception are not sent for histological examination o Anti-D prophylaxis after evacuation of a molar pregnancy o Single dose of oxytocic following evacuation if there is excessive bleeding

Answer 36

o For follow up depending on hcg levels at 56 days (8 weeks) of pregnancy event** o Considered for all women with persistently elevated hCG either after an ectopic has been excluded or after 2 consecutive treatments with methotrexate for a PUL o Complete mole – after hCG levels return to normal**:  If hcg levels have normalised within 8/52 - monthly urine hCG testing is continued for 6/12 from evacuation, follow-up for 6 months  If hcg levels have not normalised within 8/52 - monitoring continues for 6/12 from when levels became normal, follow up for 6 months from normalisation of the hCG level  Follow up (monitoring of pregnancy hormone levels) is done in the trophoblastic screening centre

Answer 37

o Pregnancy should be allowed to proceed if the mother wishes  Probability of achieving a viable baby is poor (around 25%) + there is a high risk of complications e.g. premature delivery + pre-eclampsia  No increased risk of developing persistent GTD after this type of molar pregnancy  Outcome after chemotherapy is unaffected o Prenatal invasive testing for fetal karyotype  Should be considered in cases where it is unclear if the pregnancy is a complete mole with coexisting normal twin or a possible singleton partial molar pregnancy or in cases of an abnormal placenta

Answer 38

o Recognized variants of GTN o May be treated with surgery because they are less sensitive to chemotherapy • Hysterectomy – PSTT

Answer 39

o 2/7 serum + urine samples until hCG concentrations are normal o Partial mole – surveillance may end once the hCG has returned to normal on two samples, at least 4 weeks apart o Complete mole – after hCG levels return to normal**:  If hcg levels have normalised within 8/52 - monthly urine hCG testing is continued for 6/12 from evacuation, follow-up for 6 months  If hcg levels have not normalised within 8/52 - monitoring continues for 6/12 from when levels became normal, follow up for 6 months from normalisation of the hCG level  Follow up (monitoring of pregnancy hormone levels) is done in the trophoblastic screening centre o All women to notify the screening centre at the end of any future pregnancy whatever the outcome of the pregnancy - Levels of hCG are measured 6-8/52 after the end of the pregnancy to exclude disease recurrence (o Women who have a pregnancy following a previous molar pregnancy, which has not required treatment for GTN, do not need to send a post-pregnancy hCG sample o Histological examination of placental tissue from any normal pregnancy, after a molar pregnancy, is not indicated)

Answer 40

• Chemotherapy – specialist centres – CX, Sheffield, Dundee

Answer 41

o Women being monitored after molar pregnancy should be advised not to conceive until their hCG levels have been normal for 6 months/until follow up is complete o Women who undergo chemotherapy are advised not to conceive for 1 year after completion of treatment o Women who have had a removal of a molar pregnancy are advised not to become pregnant until they have completed their hCG follow up Support o GTD nurse specialists and advisors – can be accessed wither through attending a GTD centre or via phone or both o Online support groups are available (molarpregnancy.co.uk) alongside regular drop-in support groups

Answer 42

once hCG levels have returned to normal o The use of exogenous oestrogens and other fertility drugs may be used o HRT may be used o COCP may be used o Avoid IUDs until Hcg normalised (risk of uterine perforation) o Barrier contraception until hcg normalises

Answer 43

• The need for chemotherapy following a complete mole is 8-20% and is 0.5% after a partial mole o Plateaued or rising hCG levels after evacuation o Serum hCG >20,000 IU/L more than 4 weeks after evacuation because of the risk of uterine perforation with further evacuation attempts o Raised hCG level 6 months after evacuation (even if falling) o Histological evidence of choriocarcinoma o Evidence of mets. in the brain, liver, GIT or radiological opacities >2cm on CXR o Pulmonary, vulval or vaginal metastases unless hCG concentrations are falling o Heavy vaginal bleeding or evidence of GI or intraperitoneal haemorrhage

Answer 44

o Methotrexate IM  Repeat every 48 hours  Total of 4 doses  Courses repeated every 2 weeks  Calcium folinate (folinic acid) • Orally • 30 hours after each injection of methotrexate

Answer 45

o There are a number of different regimes in use Charing cross regimen – two regiments that alternate each week = EMA/CO schedule (=etoposide/methotrexate/dactinomycin (actinomycin D)/cyclophosphamide/vincristine – formerly oncovin) o Regimen 1  Day 1 – etoposide, methotrexate and dactinomycin (actinomycin-D)  Day 2 – etoposide, dactinomycin (actinomycin – D), folinic acid rescue (starting 24 hours after beginning the methotrexate infusion) o Regimen 2  Day 8 – cyclophosphamide and vincristine (on Day 8 only) EP/EMA regime can be used as second-line if resistance develops o Regimen 1  Day 1 - etoposide, methotrexate and dactinomycin (actinomycin-D)  Day 2 – folinic acid o Regimen 2  Day 8 – etoposide, cisplatin o Treatment continued until hCG levels have returned to normal + then for a further consecutive 6/52 o Women with high-risk GTN who require multi-agent chemotherapy which includes etoposide should be advised that they may be at increased risk of developing secondary cancers

Answer 46

o Urine + serum hCG levels are monitored weekly o This gradually drops to 4-weekly urine levels in year 2 o Through further gradual reductions in frequency to 6-montly levels from year 6 o The highest risk of recurrence is in the first year * Women who have not received chemotherapy no longer need to have hCG measured after any subsequent pregnancy event * If hcg continues to rise - ?choriocarcinoma

Answer 47

Oligomenorrhoea and amenorrhoea – May predispose women to endometrial hyperplasia and cancer If the woman has prolonged amenorrhoea (oligomenorrhoea 3 or more months), abnormal vaginal bleeding or excess weight o Cyclical progestogen to induce a withdrawal bleed then o Refer for a TVUS to assess endometrial thickness  If endometrial thickening is present (>10mm) or endometrium has an unusual appearance – biopsy  If endometrium is of normal thickness + appearance – advise treatment to prevent endometrial hyperplasia – treatment which leads to a withdrawal bleed every 3 or 4 months should be recommended – options * Cyclical progestogen (e.g. methylprogesterone 10g) daily for 14 days every 1-3 months (contraception) * Low dose COCP (contraception + hyperandrogenism) * LNG-IUS – to prevent hyperplasia (contraception) * If a woman is unwilling to take cyclical hormone treatment – regular TVUSS (every 6-12 months) required to assess endometrial thickness + morphology o These treatments increase the SHBG which helps relieve androgenic symptoms o Encourage healthy lifestyle – weight loss may lead in menstrual regularity o Osteoporosis prophylaxis is not required for women with PCOS who are amenorrhoeic – they are not oestrogen deficient o US of the endometrium should be done if withdrawal bleeds do not occur o Endometrial biopsy if  Endometrial thickness is >7-10mm  There is presence of an endometrial polyp

Answer 48

• Acne o Encourage a healthy lifestyle – weight loss may reduce hyperandrogenism o COCP – first-line treatment (contraception + hyperandrogenism) o If needed, add a topical retinoid, topical antibiotic, oral antibiotic • Hirsutism o Encourage a healthy lifestyle – weight loss may reduce hyperandrogenism o Discuss methods of hair reduction and removal o Consider prescribing a COC o Eflornithine cream for facial hair

Answer 49

o Carry out an assessment to identify possible causes of infertility which may not be PCOS o 1st line – Encourage a healthy lifestyle – weight loss, stop smoking o Refer woman to be screened for GDM  All women who are planning a pregnancy should be offered an OGTT – either at pre-conception or before 20 weeks of gestation  Pregnant women should be offered another OGTT at 24-28 weeks of gestation 2nd line or 1st line in women with normal BMI o Clomiphene (up to 6 months)  Induces ovulation Given on day 2-6 of cycle (50mg) and then day 21 progesterone is neasured If ovulation has occured, continue clomifene for 6 more cycles If ovulation hasnt occured, increase dose to 100 mg  Improves pregnancy rates  Should not be used for >6 months x risk of ovarian carcinoma  Associated with an 11% risk of multiple pregnancy  women should have US monitoring during treatment  Clomiphene citrate is preferable to metformin for ovulation induction  SERM (selective oestrogen receptor modulator) – blocks ER in hypothalamus  reduces -ve feedback  more GnRH pulsatile release o Metformin  May be used instead or together with clomiphene to improve pregnancy rates  Usually added after 3 failed cycles with clomiphene  Warn women about side-effects  Metformin is not recommended in pregnancy o Or a combination of the two (clomiphene + metformin)  Used after 3 failed clomiphene cycles o 3rd line – gonadotrophins (risk: OHSS (ovarian hyperstimulation syndrome))  OHSS  multiple luteinized cysts  lots of oestrogen, progesterone, VEGF  pain, bloating  Women with PCOS who are being treated with gonadotrophins should not be offered treatment with GnRH agonist concomitantly – does not improve pregnancy rates, increases the risk of ovarian hyperstimulation o 3rd line – Surgery o Ovarian electrocautery  Should be considered for selected anovulatory patients (esp. those with normal BMI) as an alternative to ovulation induction o Laparoscopic ovarian drilling – destroys ovarian stroma + prompts ovulatory cycles

Answer 50

• Obstructive sleep apnoea o Due to androgen excess o Ask about snoring + daytime fatigue/somnolence o If there are symptoms, refer for investigation and treatment

Answer 51

o Lifestyle advice – dietary modification + exercise o Weight reduction o Treatment of hirsutism/androgenic symptoms (specialties guide, not in NICE)  Co-cyprindiol (dianette)= Cyproterne acetate + ethinylestradiol  Used in PCOS complicated by hirsutism + acne  Also acts as contraception  COCP + enhanced anti-antrogenic activity o Cyproterone acetate (antiandrogen) o Topical eflornithine cream (hyperandreognism) o GnRH analogues (reserved for women who are intolerant to other therapies) o Surgical treatment (laser or electrolysis) o Contraception  COCP – To control menstrual irregularity  If RF to the COPC – progestogens may be used to induce bleeds to protect the endometrium  IUS may be used as endometrial protection o Metformin  Has been increasingly used off-licence for PCOS – NICE suggests it’s side-effects and cost outweigh its benefits + any as yet unproven, long-term health benefits o Orlistat  Can help with weight loss in overweight/obese women  May improve testosterone + insulin sensitivity with similar efficacy to metformin  May be helpful in reducing hyperandrogenaemia

Answer 52

``` • Lifestyle interventions o Aim for BMI 20-25 o BMI <19 – weight gain o BMI >30 – weight loss  BMI >30 – are likely to take longer to conceive, losing weight is likely to increase their chance of conception, men with BMI >30 are likely to have reduced fertility ``` o Exercise, dietary advice, weight loss advice o Stop smoking (impairs fertility, smoking in pregnancy increaes risk of miscarriage, obstetric complications, IUGR, delayed reading ability, association between smoking and reduced semen quality) o Cut down on drinking (no more than ½ units per week) o Avoid illicit drugs (cannabis can impair ovulation, cocaine can cause tubual infertility) o Folic acid * Wait for regular intercourse to be established for at least 12 months (every 2-3 days) * Start performing ix after 12 months • If unexplained sub-fertility, mild endometriosis, male factor sub-fertility – try for another 12 months o After this consider IVF

Answer 53

* Treatment of ejaculatory failure can restore fertility without the need for invasive methods of sperm retrieval or the use of associated reproduction procedures * Persistent azoospermia is incompatible with fertility – the couple may wish to consider donor sperm Medical management • Hypogonadotrophic hypogonadism – gonadotrophin drugs Surgical management • Obstructive azoospermia - surgical correction of epididymal blockage o Surgical correction should be considered as an alternative to surgical sperm recovery + IVF * Surgery for varicoceles should not be offered as it does not improve pregnancy rates * In men with cryptorchidism and azoospermia, orchidopexy may result in spermatozoa being present in the ejaculate

Answer 54

* Increasing their body weight if they have a BMI <19 * Moderating their exercise levels if they undertake high levels of exercise * Offer pulsatile administration of GnRH or gonadotrophins with LH activity to induce ovulation

Answer 55

• Lose weight If BMI >30 • 1st line – Ovulation induction – Offer one of the following treatments o Clomiphene citrate (SERM) o Metformin o Combination of the above o lowest effective dose and duration of use • For women who are taking clomiphene citrate o Offer US monitoring during at least the first cycle of treatment to ensure that they are taking a dose that minimises the risk of multiple pregnancy o Do not continue treatment for longer than 6 months • Inform women of SE of metformin – N+V, other GI disturbances • 2nd line – If resistant to clomifiene o Laparoscopic ovarian drilling  Removes endometrium – reduce amount of androgen-producing tissue or o Combined treatment with clomiphene citrate + metformin (if not already offered as first line) or o Gonadotrophins  Women with PCOS who are being treated with gonadotrophins should not be offered treatment with GnRH agonist concomitantly – does not improve pregnancy rates, increases the risk of ovarian hyperstimulation  Women who are offered ovulation induction with gonadotrophins should be informed about the risk of multiple pregnancy + ovarian hyperstimulation --> ovarian US monitoring to measure follicular size + number to reduce those risks

Answer 56

* Tubal microsurgery + laparoscopic tubal surgery --> Mild tubal disease – tubal surgery may be more effective than no treatment * Tubal catheterisation or cannulation --> Proximal tube obstruction --> selective salpingography + tubal catheterisation or hysteroscopic tubal cannulation * Surgery for hydrosalpinges before IVF --> women with hydrosalpinges should be offered salpingectomy, preferably by laparoscopy before IVF as this improves the chance of a live birth * Uterine surgery --.>women with amenorrhoea who are found to have IUA --> hysteroscopic adhesiolysis * Operative laparoscopy  adhesions, ovarian cyst, endometriosis * Myomectomy, hysteroscopy, laparoscopy, laparotomy, fibroid embolisation  fibroids

Answer 57

* Do not offer oral ovarian stimulation agents (e.g. clomifine citrate, anastrozole, letrozole) * Inform women with unexplained infertility that clomifene citrate as a stand-alone treatment does not increase the chances of a pregnancy or a live birth * Try to conceive for a total of 2 years before considering IVF * Offer IVF to women with unexplained fertility who have not conceived after 2 years of regular unprotected sexual intercourse

Answer 58

* Refers to procedures whereby treated or manipulated sperm are brought into proximity with oocytes * It includes o IUI – intrauterine insemination with partner or donor sperm in natural or stimulated cycles o Gamete intrafallopian transfer (GIFT) o IVF o Intracytoplasmic sperm injection (ICSI)

Answer 59

• Involves the introduction of prepared sperm into the uterine cavity around the time of ovulation (spontaneous or induced) • Consider unstimulated intrauterine insemination as a treatment option in the following groups as an alternative to vaginal sexual intercourse o People who are unable to or would find it very difficult to have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem o People with conditions that require specific consideration in relation to methods of conception (e.g. HIV +ve partner) o People in same-sex relationships o Idiopathic, anovulation unresponsive to ovarian induction, mild male factor, minimal to mild endometriosis • Offer 12 cycles before IVF is considered • For people with unexplained infertility, mild endometriosis or mild male factor infertility who are having regular unprotected sexual intercourse o Do not routinely offer intrauterine insemination o Advise them to try to conceive for a total of 2 years before IVF will be considered

Answer 60

• Full cycle of IVF (+/- ICSI) = 1 episode of ovarian stimulation + the transfer of any resultant fresh/frozen embryo • In women <40 y/o who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where >6 are by intrauterine insemination) o Offer 3 full cycles of IVF +/- ICSI (intracytoplasmic sperm injection) o Those women who reach 40 years during treatment should not be offered further cycles o If the woman reaches the age of 40 during treatment, complete the current full cycle but do not offer further full cycles • In women 40-42 y/o who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where >6 are by intrauterine insemination) – offer 1 full cycle of IVF (+/- ICSI) provided the following 3 criteria are fulfilled o They have never previously had IVF o There is no evidence of low ovarian reserve o There has been a discussion of the additional implication of IVF + pregnancy at this age • When IVF is used and a top-quality blastocyst is available, a single embryo transfer is recommended to minimise the numbers and associated risks of a multiple pregnancy

Answer 61

blocked tubes male minor factor idiopathic unsuccessful ovarian induction or 12 failed cycles of intrauterine insemination

Answer 62

• Concept: leave the egg and sperm in a petri dish and they will fertilise each other • Pre-treatment in IVF COCP to suppress the woman's own hormone production • Down regulation and other regimens to avoid premature luteinising hormone surges in IVF o GnRH agonist or GnRH antagonist as part of the gonadotrophin-stimulated IVF treatment cycles o Only offer GnRH agonists to women who have a low risk of ovarian hyperstimulation syndrome • Controlled ovarian stimulation in IVF o Use ovarian stimulation as part of IVF treatment o Use either urinary or recombinant gonadotrophins for ovarian stimulation o Offer women US monitoring (+/- oestradiol levels) for efficacy and safety throughout ovarian stimulation o Clomiphene citrate-stimulated and gonadotrophin-stimulated IVF cycles have higher pregnancy rates per cycle than natural cycle IVF o Do not offer women natural cycle IVF treatment o Limit the use of ovulation induction or ovarian stimulation agents to the lowest effective dose and duration of use • Triggering ovulation in IVF o Offer women human chorionic gonadotrophin (urinary or recombinant) to trigger ovulation in IVF treatment o Offer US monitoring of ovarian response as an integral part of the IVF treatment cycle o Be prepared to prevent, diagnose and manage ovarian hyperstimulation syndrome • Oocyte and sperm retrieval in IVF o Transvaginal retrieval of oocytes • Embryo transfer strategies in IVF o US-guided embryo transfer o Replacement of embryos into a uterine cavity with a endometrium of <5mm thickness is unlikely to result in pregnancy – not recommended o Evaluate embryo quality at both cleavage and blastocyst stages o Offer cryopreservation to store any remaining good-quality embryos after embryo transfer o The likelihood of a live birth after replacement of frozen-thawed embryos is similar for embryos replaced during natural cycles and hormone-supplemented cycles • Luteal phase support after IVF o Offer women progesterone for luteal phase support after IVF treatment for 8 weeks o Do not routinely offer women hCG for luteal phase support after IVF treatment - increased likelihood of ovarian hyperstimulation syndrome

Answer 63

``` • Indications o Severe deficits in semen quality o Obstructive azoospermia o Non-obstructive azoospermia o Also considered for couples in whom a previous IVF treatment cycle has results in failed or very poor fertilisation ``` * Where the indication for ICSI is a severe deficit of semen quality or non-obstructive azoospermia, the man’s karyotype should be established (after genetic counselling) * ICSI improves fertilisation rates compared to IVF alone, but once fertilisation is achieved the pregnancy rate is not better than with IVF * Most common treatment for male infertility * Sperm directly injected into the egg (bypass natural barriers)

Answer 64

• Indications o Obstructive azoospermia o Non-obstructive azoospermia o Severe deficits in semen quality in couples who do not wish to undergo ICSI • Should also be considered in conditions such as o Where there is a high risk of transmitting a genetic disorder to the offspring o Where there is a high risk of transmitting infectious disease to the offspring or woman from the man o Severe rhesus isoimmunisation o Single women

Answer 65

* Women with no RF in their hx should be offered tubal assessment after 3 cycles if treatment by donor insemination has been unsuccessful * Women who are ovulating regularly should be offered a minimum of 6 cycles of donor insemination without ovarian stimulation – to reduce the risk of multiple pregnancy and its consequences * Women should be offered intrauterine insemination in preference to intracervical insemination – improved pregnancy rates

Answer 66

• The use of donor oocytes is considered effective in managing fertility problems associated with the following conditions o Premature ovarian failure o Gonadal dysgenesis incl. Turner’s syndrome o Bilateral oophorectomy o Ovarian failure following chemotherapy or radiotherapy o Certain cases of IVF treatment failure • Should also be considered o Where there is a high risk of transmitting a genetic disorder to the offspring o Women whose egg quality is poor o Previous surgery/chemotherapy where ovarian function was adversely affected

Answer 67

• Cryopreservation of semen, oocytes and embryos o Do not use a lower age limit for cryopreservation for fertility preservation in people diagnosed with cancer o Offer sperm cryopreservation to men and adolescent boys who are preparing for medical treatment for cancer that is likely to make them infertile  Use freezing in liquid nitrogen vapour as the preferred cryopreservation technique for sperm o Offer oocyte or embryo cryopreservation as appropriate to women of reproductive age (incl. adolescent girls) who are preparing for medical treatment for cancer that is likely to make them infertile if  They are well enough to undergo ovarian stimulation and egg collection and  This will not worsen their condition and  Enough time is available before the start of their cancer treatment  In cryopreservation of oocytes and embryos, use vitrification instead of controlled-rate freezing o Store cryopreserved material for an initial period of 10 years o Offer continued storage of cryopreserved sperm, beyond 10 years, to men who remain at risk of significant infertility

Answer 68

• Ovarian hyperstimulation syndrome (OHSS) o Most serious complication o Ovaries become hyperstimulated  exposure to hCG  pro-inflammatory mediators  ovarian enlargement, increased vascular permeability (third spacing), prothrombotic state o May occur when ovarian stimulation techniques are used o Lower abdominal discomfort, N+V+D, abdominal distension o Mx – symptomatic management, fluid replacement, VTE prophylaxis o Signs of severe disease incl. need for hospital mx – ascites, rapid weight gain, hypotension, tachycardia, oliguria, U+E/other metabolic anomalies

Answer 69

• Viral transmission o Sperm washing if man is HIV +ve and not compliant with HAART or has a plasma viral load >50 copies/ml, pre-exposure prophylaxis in woman, vaccination for Hep B

Answer 70

o DA agonists e.g. bromocriptine, cabergollinr

Answer 71

* Concept: leave the egg and sperm in a petri dish and they will fertilise each other * Pre-treatment in IVF * Down regulation and other regimens to avoid premature luteinising hormone surges in IVF * Controlled ovarian stimulation in IVF * Triggering ovulation in IVF * Oocyte and sperm retrieval in IVF * Embryo transfer * Luteal phase support after IVF

Answer 72

Treatment • Observation with follow up o The majority of cases of endometrial hyperplasia without atypia will regress spontaneously during follow-up • Progestogen treatment o First line medical treatment o LNG-IUS (1st line) > oral continuous progestogens (2nd line)  LNG-IUS – first line medical treatment, higher disease regression rate, more favourable bleeding profile, fewer adverse effects  Minimum of 6 months – in order to induce histological regression of endometrial hyperplasia without atypia  Women should be encouraged to retain the LNG-IUS for up to 5 years – reduced risk of relapse  Cyclical progestogens should not be used – less effective in inducing remission o Higher disease regression rate compared with observation alone o Also used in women who fail to regress following observation alone o Used in symptomatic women with abnormal uterine bleeding • Hysterectomy o Not considered first line – progestogen therapy is very effective o Indicated in women not wanting to preserve their fertility when  There is no histological regression of hyperplasia despite 12 months of treatment – risk of cancer is high and chances of disease regression are low  Progression to atypical hyperplasia occurs during follow up  There is relapse of endometrial hyperplasia after completing progestogen treatment  There is persistence of bleeding symptoms  The woman declines to undergo endometrial surveillance or comply with medical treatment o Post-menopausal women – TAH + BSO o Pre-menopausal women – TAH +/- BSO o Laparoscopic approach

Answer 73

``` • TAH o Risk of underlying malignancy or progression to cancer o Laparoscopic approach o Post-menopausal women – TAH + BSO o Pre-menopausal women – TAH +/- BSO ```

Answer 74

Fertility preserving • Counsel woman about the risks of underlying malignancy + subsequent progression to endometrial cancer • Rule out invasive endometrial cancer or co-existing ovarian cancer • LNG-IUS – first line • Orla progestogens – second line • Once fertility is no longer required – hysterectomy

Answer 75

* Systemic oestrogen only HRT should not be used in women without a uterus * All women taking HRT should be encouraged to report unscheduled vaginal bleeding promptly • Women with endometrial hyperplasia taking sequential/cyclincal HRT o Change to continuous progestogen intake (LNG-IUS or continuous combined HRT preparation)

Answer 76

* Complete removal of uterine polyps * Endometrial biopsy to sample the background endometrium Monitoring • Endometrial surveillance should include endometrial sampling by OP endometrial biopsy o Minimum of 6-monthly intervals o At least 2 consecutive 6-monthyl negative biopsies should be obtained prior to discharge o Once 2 consecutive negative endometrial biopsies have been obtained - endometrial biopsy once a year • If abnormal vaginal bleeding recurs after completion of treatment – may indicate disease relapse

Answer 77

• Routine endometrial surveillance should include endometrial biopsy • Review intervals should be every 3 months until 2 consecutive negative biopsies are obtained o Long-term follow-up with endometrial biopsy every 6-12 months until a hysterectomy is performed Women wishing to conceive • Disease regression should be achieved on at least 1 endometrial sample before women attempt to conceive • Refer women to a fertility specialist – assisted reproduction has a higher birth rate + prevents relapse

Answer 78

o TAH + BSO (+ lymphadenectomy) o TAH – laparoscopy or laparotomy o Lymphadenectomy  For patients with stage I disease it is no beneficial with regards to survival or recurrence  Important for staging and as a guide for adjuvant therapy o Sentinel lymph node mapping – may be considered during surgical staging to assess for pelvic lymph node mets (non-inferior to and results in lower morbidity than lymphadenectomy) o If woman is low risk + wants to preserve fertility  Low-dose megestrol  Aggressive monitoring + hysteroscopy with endometrial sampling every 3-6/12  Patients advised to consider hysterectomy once childbearing is completed o Stage IA disease  Without myometrial invasion or With myometrial invasion + Low-intermediate risk* – adjuvant therapy not required  With myometrial invasion + High-intermediate risk* – adjuvant radiotherapy (vaginal brachytherapy)  *based on age and the following RF – tumour grade 2 or 3, lymphovascular space invasion, outer third myometrial invasion o Stage IB or II classified as low risk – no adjuvant therapy required o Stage IB or II classified as high-intermediate risk or high risk  Adjuvant radiotherapy (vaginal brachytherapy)  If deep myometrial invasion, gross cervical involvement +/or tumour grade 3 – adjuvant EBRT +/- vaginal brachytherapy  Chemotherapy may be offered – paclitaxel + carboplatin

Answer 79

o II TAH + BSO o IIB Radical hysterectomy + systematic pelvic node assessment/clearance  Para-aortic lymphadenectomy may also be considered  Radical hysterectomy = TAH + BSO + lymphadenectomy + resection of the parametrium + upper part of the vagina o Stage IB or II classified as low risk – no adjuvant therapy required o Stage IB or II classified as high-intermediate risk or high risk  Adjuvant radiotherapy (vaginal brachytherapy)  If deep myometrial invasion, gross cervical involvement +/or tumour grade 3 – adjuvant external beam radiotherapy EBRT) +/- vaginal brachytherapy  Chemotherapy may be offered – paclitaxel + carboplatin

Answer 80

o Maximal de-bulking surgery + adjuvant chemotherapy + radiotherapy (EBRT)  Chemo – paclitaxel + carboplatin o Stage IV – may take palliative approach – low dose radio/high dose progesterone

Answer 81

o Supportive care o Isolated + symptomatic recurrence  Salvage radiotherapy (combination of EBRT + vaginal brachytherapy) +/or  Surgical resection o Oestrogen/progesterone receptor -ve tumour  Palliative chemo – paclitaxel + carboplatin o Oestrogen/progesterone receptor +ve tumour  Better prognosis  Hormone therapy with progestin or aromatase inhibitor – tamoxifen or megestrol or medroxyprogesterone or leuprorelin or letrozole  Usually – tamoxifen alternating with medroxyprogesterone o Microsatellite instability-high or mismatch repair deficient tumour  Pembrolizumab – programmed death receptor-1 blocking monoclonal antibody (immune checkpoint inhibitor) o Vaginal recurrence – radiotherapy

Answer 82

* if surgery not possible because of medical contra-indications – external beam radiotherapy and intracavity radiotherapy may be used * frail elderly women no suitable for surgery – progestogen therapy

Answer 83

o Localised disease – TAH + BSO o High risk patients – radio o Progestogen therapy as an alternative to TAH suitable for  Pre-cancer  Early-stage low-grade endometrial cancers  Frail elderly women not suitable for surgery

Answer 84

o Primary infertility due to PCOS – RF for pre-menopausal endometrial caner o Alternatives to hysterectomy for pre-menopausal women are only possible for pre-cancer or early-stage low-grade endometrial cancers o Hormone therapy (PO progestogens or LNG-IUS) – associated with moderate response and high relapse rates o Consider ovarian conservation and/or stimulation for egg retrieval and surrogacy

Answer 85

* menopausal symptoms after BSO * bladder instability following surgery – bladder pain, UI, UU, haematuria, symptoms of cystitis * vaginal stenosis, atrophy and fibrosis following radiotherapy * long term sexual dysfunction

Answer 86

* High risk women should be offered genetic screening and counselling * May also be offered prophylactic salpingo-oophorectomy * Women diagnosed with ovarian cancer should be offered genetic screening for the relevant gene mutations

Answer 87

ascites and/or pelvic/abdominal mass

Answer 88

• Optimal surgical staging o Midline laparotomy to allow thorough assessment of the abdomen + pelvis - for histological confirmation, staging and tumour debulking o TAH + BSO o Infracolic omentectomy o Biopsies of any peritoneal deposits o Random biopsies of the pelvic-abdominal peritoneum o Retroperitoneal lymph node assessment  Involves sampling retroperitoneal lymphatic tissue from the para-aortic area + pelvic side walls if there is a palpable abnormality or random sampling if there is no palpable abnormality • Debulking surgery o Complete resection of all macroscopic disease, complete cytoreduction o If complete cytoreduction is not possible – there is still benefit to debulking surgery provided optimal cytoreduction can be achieved (i.e. residual tumour <1cm) o Other surgical procedures may be performed during debulking surgery to achieve complete or optimal cytoreduction, incl. bowel resection, appendicectomy, diaphragm stripping and splenectomy o Debulking surgery may facilitate effective adjuvant chemo • Adjuvant Chemotherapy o First line chemotherapy = paclitaxel + platinum-based compound or platinum-based therapy alone (cisplatin or carboplatin) o Stage Ia or Ib, Grade 1 or 2 – do not offer adjuvant chemotherapy to women who have had optimal surgical staging o Stage Ic or Grade 3 – adjuvant chemotherapy (6 cycles of carboplatin) • Genetic risk evaluation and genetic testing (e.g. BRCA mutations) should also be carried out if not done previously • In young women with early stage low-risk disease who want to preserve their fertility (i.e. germ cell tumours) o Unilateral salpingo-oophorectomy + staging

Answer 89

* Surgery either before chemo or after neoadjuvant chemo * First line chemotherapy = paclitaxel + platinum-based compound or platinum-based therapy alone (cisplatin or carboplatin) [IV, 3-6 cycles, 3 weeks apart in OPD] [NICE pathways] • Stages III- IV also need maintenance therapy after first line chemotherapy o Olaparib – BRCA+ advanced high grade epithelial ovarian/fallopian tube or primary peritoneal cancer that has responded to first-line platinum-based chemotherapy  Maintenance Olaparib can be continued up to 2 years or until disease progression or unacceptable toxicity o Niraparib - high grade epithelial ovarian/fallopian tube or primary peritoneal cancer after a complete or partial response to first-line platinum-based chemotherapy  Maintenance Niraparib can be continued up to 3 years or until disease progression or unacceptable toxicity o Olaparib + bevacizumab - high grade epithelial ovarian/fallopian tube or primary peritoneal cancer when there has been a complete or partial response after first-line platinum-based therapy + bevacizumab and the cancer is associated with HRD (homologous recombination deficiency)  Should only be considered for patients who received bevacizumab as first-line chemo * Chemotherapy is not useful in sex cord stromal tumours - surgery is mainstay * Patients will undergo a CT scan following completion of chemo to assess response to treatment • Follow-up includes clinical examination + ca125 measurement o ca125 tends to rise prior to the onset of clinical evidence in disease recurrence

Answer 90

• Platinum based combination chemotherapy o Paclitaxel or PLD • Hormonal therapies o Where there is platinum- resistant recurrence, particular subtypes or a wish to avoid chemo o Tamoxifen, aromatase inhibitors, LHRH agonists • Bevacizumab o Used in the treatment of the first recurrence of platinum-sensitive advanced ovarian cancer that has not been previously treated with bevacizumab or other VEGF inhibitors or VEGF receptor targeted agents • However, when disease recurs, treatment is largely palliative

Answer 91

• Urgent surgical exploration (laparoscopy or laparotomy) to manage possible ovarian torsion/cyst rupture or haemorrhage o Torsion - If operated within 6 hours of onset of symptoms – tissue will remain viable • Resus • Broad spectrum antibiotics

Answer 92

• Conservative/expectant o <50mm in diameter simple or functional ovarian cyst – will almost always resolve within 3 menstrual cycles, no FU needed o 50-70mm in diameter simple ovarian cyst – yearly US FU o >70mm in diameter simple ovarian cyst – MRI +/- surgical intervention  Laparoscopy > laparotomy  Laparotomy – presence of large masses with solid components (e.g. large dermoid cysts) o Watchful waiting for 2-3 cycles is appropriate + if cyst persists then surgical management is often indicated o Ovarian cysts that persist/increase in size are unlikely to be functional – need surgical management • Surgery o If conservative mx fails o If criteria for surgery are met:  Ovarian cysts that persist or increase in size after several cycles – unlikely to be functional Mature cystic teratomas (dermoid cysts) have been shown to grow over time, increasing the risk of pain + ovarian accidents  Persistent simple ovarian cysts >5-6cm, especially If symptomatic  Complex, suspicious, multiloculated ovarian cysts o Spillage of cyst contents should be avoided where possible – preoperative and intraoperative assessment cannot absolutely preclude malignancy  Surgical specimen should be removed without intraperitoneal spillage in a laparoscopic retrieval bag via the umbilical port (quicker + results in less postoperative pain + a quicker retrieval time than when using lateral ports of the same size) or transvaginally o Preoperative assessment – using RMI 1 or US rules (IOTA group) o Children + younger women – laparoscopic cystectomy > oophorectomy o Laparoscopic > open surgery  Laparoscopy – gold standard for the management of benign ovarian masses – lower postoperative morbidity, shorter recovery time  Laparoscopy may need to be upgraded to laparotomy when malignancies are discovered  Laparotomy – presence of large masses with solid components (e.g. large dermoid cysts)

Answer 93

• Conservative/expectant o Asymptomatic, simple, unilateral, unilocular ovarian cysts, <5cm, RMI <200, normal CA125 --> Repeat CA125, TVS +/- TAS in 4-6 months o Low risk of malignancy o Discharge after 1 year if the cyst remains unchanged/reduces in size + normal ca125 • Laparoscopy o RMI <200, symptomatic, non-simple features, >5cm, multilocular, bilateral / suspicious / persistent / complex / solid – should undergo TVUS to determine RMI o BSO rather than cystectomy o Counsel preoperatively that a full staging laparotomy will be required if evidence of malignancy is revealed o Surgical specimen should be removed without intraperitoneal spillage in a laparoscopic retrieval bag via the umbilical port (quicker + results in less postoperative pain + a quicker retrieval time than when using lateral ports of the same size) or transvaginally • Laparotomy (full laparotomy + staging procedure) o All ovarian cysts suspicious of malignancy (RMI >200, CT findings, clinical assessment or findings at laparoscopy) o If malignancy is revealed during laparoscopy or from subsequent histology --> refer woman to a cancer centre for further management ``` o Staging laparotomy  Performed through a midline incision  Cytology – ascites or washings  TAH, BSO + omentectomy  Biopsies from any suspicious areas  May include bilateral selective pelvic and para-aortic lymphadenectomy ``` • Aspiration of ovarian cyst o Not recommended for the management of ovarian cysts in postmenopausal women o Symptoms control in women with advanced malignancy who are unfit to undergo surgery or further intervention • Team o Low risk of malignancy (RMI <200) – general gynaecologist o High risk of malignancy – trained gynaecological oncologist https://pbs.twimg.com/media/Cnu4MxmXEAE320x.jpg

Answer 94

```  Unilateral  Unilocular (no solid parts)  Premenopausal (3-10cm)  Postmenopausal (2-6cm)  Normal ca125  No free fluid ```

Answer 95

o Ovarian torsion  Laparoscopy with uncoiling of the affected ovary + possible oophoropexy  Salpingo-oophorectomy – if severe vascular compromise / peritonitis / tissue necrosis o Haemorrhagic cyst – immediate surgical intervention o Pseudomyxoma peritonei – surgical debulking

Answer 96

* Inform patients of the small risk of neoplastic change * Safety-netting – inform the doctor if they notice a change in appearance or texture (e.g. lump or hardening of skin) or if there is a major change in symptoms * Treatment recommended if patients have features of active disease e.g. ecchymosis, hyperkeratosis, progressive atrophy

Answer 97

* Inform patients of the small risk of neoplastic change * Safety-netting – inform the doctor if they notice a change in appearance or texture (e.g. lump or hardening of skin) or if there is a major change in symptoms • Advice o Wash with bland emollients – aq cream, soap substitute, avoid topical irritants + tight clothing, use lubricants if necessary o Seek medical attention if possible signs of malignancy – persistent lump, change in texture of skin (e.g. thickening), non-healing ulcer/erosion • Ultra-potent topical steroids • Clobetasol propionate o Reducing course of clobetasol propionate 0.05% - half a fingertip unit o OD at night for 1/12 - alternate nights for 1/12 - twice weekly for 1/12 o Review at 3 months • Alternative regimens – treat secondary infection if secondary infection is a concern o Ultra-potent topical steroid with antibacterial + antifungal – e.g. Dermovate or generic equivalent (clobetasol with neomycin + nystatin) o An alternative preparation that combats secondary infection (Fucibet cream) o Should only be used for a short period of time to clear infection • Unlicensed treatments o Topical calcineurin inhibitors – tacrolimus, pimecrolimus o Oral retinoid – acitretin  Severely teratogenic  Pregnancy must be avoided for 2 years after finishing treatment o UVA1 phototherapy * Successful treatment – hyperkeratosis/ecchymoses/fissuring/erosions resolve but atrophy/colour change remain * Maintenance treatment may be required with PRN use of very potent steroids • Treatment failure o Check compliance o Correct diagnosis? There may be an additional problem e.g. infection or allergy to the preparation o Complication • If resistant to initial steroid treatment o Biopsy • Pregnancy and breastfeeding o Topical steroids are safe to use while pregnant or breast feeding o Topical calcineurin inhibitors are contraindicated o Retinoids are absolutely contra-indicated during pregnancy + at least 2 years before

Answer 98

• After 3 months to assess response to treatment • Long term FU needed for women with LS o Particularly for patients on long-term steroids and poorly controlled LS • Stable disease / Patients who respond well to treatment + need only small amounts of steroids o Annual review o Can be done in primary care o Safety-netting – report immediately any persistent new lumps, skin changes, erosions, ulcers, sore area, change in symptoms or change in appearance

Answer 99

• Scarring o Common – may cause urinary symptoms or sexual dysfunction o Labial fusing – urinary difficulties, dyspareunia o May require surgery – meatal dilatation, vulval surgery • Constipation o Due to anal fissures o Prescribe softening laxatives • Squamous cell carcinoma o Small risk of SCC of the vulva (3.5-5%) o About 60% of vulval SCC arise on a background of LS o Long term follow-up o Warn patients about signs of malignancy + biopsy any suspicious lesions o Extragenital lesions – do not appear to have increased risk of malignancy • Dysesthesia o Vulvodynia, vestibulodynia – neuropathic type pain, does not respond to steroid treatment o Topical local anaesthetics (e.g. 5% lidocaine ointment) • Clitoral pseudocyst o Due to build-up of debris under clitoral adhesions o Refer to gynae if pain or recurrent infection • Sexual dysfunction

Answer 100

* Gynaecologists should ask all women from communities that traditionally practise FGM whether they have had the procedure * Women attending maternity, family planning, gynaecology and urology clinics (among others) should be asked routinely about the practice of FGM • NHS hospitals have to record o If a patient has had FGM o If there is a FH of FGM o If an FGM-related procedure has been carried out on a woman • Reporting to the police and social services Mandatory reporting: o FGM in girls <18 should o All women and girls with acute or recent FGM o If the unborn child or any related child is considered at risk o The mandatory duty to tell the appropriate agency will not apply to at risk or suspected cases >18 years o It is not mandatory to report all pregnant women to social services or the police o Individual risk assessment should be made using an FGM safeguarding risk assessment tool • When a woman with FGM is identified o HCP must explain UK law on FGM o HCP must record + report (make a referral to police and/or social services) o Check to see if there are young girls in the family who are at risk • Referral to FGM services o Can be made by the GP to a hospital gynaecology clinic o Women should be able to self-refer  All women should be offered referral for psychological assessment and treatment, testing for HIV, HBV, HCV and sexual health screening  Where appropriate, women should be referred to gynaecological subspecialties e.g. psychosexual services, urogynaecology, infertility o All children with FGM or suspected FGM should be seen within child safeguarding services ``` • Specialist multidisciplinary FGM services should offer o Information and advice about FGM o Child safeguarding risk assessment o Gynaecological assessment o De-infibulation o Access to other services ```

Answer 101

• De-infibulation o May be required prior to gynaecological procedures e.g. surgical management of miscarriage, TOP o Counsel and offer procedure before pregnancy, ideally before first sexual intercourse o Adequate analgesia to avoid flashbacks of FGM o Incision along the vulval incision scar o Prior urinary infection screening + given appropriate antibiotics o Access to specialist services + support groups is necessary • Clitoral reconstruction o Should not be performed – unacceptable complication rates without conclusive evidence of benefit • During pregnancy  Ensure all the relevant information is documented in the clinical records  Refer to a designated consultant obstetrician/midwife with responsibility for FGM patients  Refer for psychological assessment and treatment  Inspect vulva to determine the type of FGM + whether de-infibulation is indicated • If the introitus is sufficiently open to permit vaginal examination + if the urethral meatus is visible – de-infibulation is unlikely to be necessary  Offer screening for HCV in addition to the other routine AN screening (HBV, HIV, syphilis) o De-infibulation in pregnancy  May be performed AN / in the first stage of labour / at the time of delivery / perioperatively after a C-section  Can usually be performed under LA in a delivery suite room  Re-infibulation will not be undertaken under any circumstances o Intrapartum care  Labial tears in women with FGM should be managed in the same manner as in women without FGM – repairs should be performed where clinically indicated o Postnatal  if EMCS • Consider + Discuss the option of perioperative de-infibulation (i.e. just after C-section) • F/U in gynae OP or FGM clinic so that de-infibulation can be offered before a subsequent pregnancy

Answer 102

• Reporting to the police and social services Mandatory reporting: o FGM in girls <18 should o All women and girls with acute or recent FGM o If the unborn child or any related child is considered at risk o The mandatory duty to tell the appropriate agency will not apply to at risk or suspected cases >18 years o It is not mandatory to report all pregnant women to social services or the police

Answer 103

NSAIDs such as mefenamic acid Paracetamol If painkillers for e.g. NSAIDs or paracetamol are ineffective COCP Medroxyprogesterone acetate (progesterone) Both COCP + medroxyprogesterone acetate reduce menstruation, which can improve symptoms associated with the proliferation of ectopic endometrial tissue.

Answer 104

Leuprorelin acetate GnRH analogue Works by preventing FSH/LH release from the anterior pituitary Hysterectomy For severe, refractory cases after laparoscopic excision and if the patient does not want to have children.

Answer 105

NSAIDs Mefenamic acid Ibuprofen are effective in up to 80% of women Work by inhibiting prostaglandin production COCP used second line

Answer 106

• Anticonvulsants that induce liver enzymes (phenytoin, barbiturates, primidone, topiramate, carbamazepine, oxacarbazepine) o Depot medroxyprogesterone acetate o Should be scheduled every 10-weekly o Rather than 12-weekly ``` o IUCD o LNG-IUS o Barrier methods o Natural family planning methods o NOT recommended: POP, progestogen implant ```

Answer 107

o Copper IUD  preferred choice for emergency contraception for WWE taking enzyme AEDs o Effectiveness of levonorgestrel + possibly ulipristal decrease in women taking enzyme-inducing drugs + possibly for 4 weeks after stopping o Dose of levonorgestrel - increase to a total of 3mg taken as a single dose

Answer 108

ectopic - methotrexate miscarriage - misoprostol TOP - mifepristone + misoprostol

Answer 109

Anti-D prophylaxis • Offer if abortion >10+0w + RhD -ve • Do not offer if medical abortion <10+0w • Consider if surgical abortion <10+0w + RhD -ve Antibiotics • Do not routinely offer abx prophylaxis for medical abortion • Offer abx prophylaxis for surgical abortion • PO doxycycline 100mg BD 3/7 or metronidazole VTE prophylaxis • For women who need VTE prophylaxis – LMWH for at least 7/7 after abortion • If at high risk of thrombosis consider starting LMWH before abortion + giving it for longer afterwards

Answer 110

Methods • Choice between medical + surgical abortion up to + incl. 23+6w o Surgical abortion can be performed shortly after 23+6w gestation only if feticide is given <23+6w) o (feticide – the injection of digoxin or KCl into the fetus or an injection of digoxin into the amniotic cavity >21+6w to stop the fetal heart before an abortion + to eliminate the possibility of aborted fetus showing any signs of life) • Mifepristone o Anti-progestogen o Blocks the action of progesterone, halting the pregnancy and relaxing the cervix (often referred to as RU486) o Result in uterine contractions, bleeding from the placentl bed, sensitisation of uterus to prostaglandins o Reduces the treatment to delivery interval in TOP • Misoprostol o Prostaglandin E1 analogue o Used off-licence in medical TOP + for cervical preparation in TOP o Softens the cervix + Stimulates uterine contractions • Gemeprost o Prostaglandin E1 analogues o Softens + dilates the cervix before surgical TOP in the first trimester + therapeutic TOP in the second trimester Surgical <13 weeks – Vacuum aspiration – surgical dilation + suction of uterine contents • Involves gently dilating the cervix and using vacuum suction to evacuate the uterus • Can be performed under LA or GA • Cervix primed to make procedure easier • Prophylactic antibiotics (metronidazole) can be given to reduce the risk of infection >15 weeks – surgical dilation and evacuation of uterine contents or late medical abortion (induces “mini-labour”) • Required good cervical dilation to remove larger fetal parts • Extraction using aspiration + other instruments (e.g. forceps) • USS to confirm evacuation

Answer 111

● Mifepristone is oral ○ <9+6w – misoprostol can be taken at home or in the clinic or hospital ○ >10w – misoprostol can be taken in the clinic or hospital (increased risk of bleeding + discomfort) ● Misoprostol can be given PB, buccal or sublingual ● Analgesia (paracetamol/ ibuprofen) recommended (cramps) ● Offer if abortion >10+0w + RhD -ve ● Do not offer if medical abortion <10+0w < 9+0w Give them the choice of having mifepristone PO + misoprostol PV at the same time o Misoprostol be administered at home provided that the patient is easy to follow + can seek medical attention if necessary o Expect bleeding for 2 weeks, do a pregnancy test in 2-3w If given at the same time, explain that o The risk of ongoing pregnancy may be higher and that it may increase with gestation o It may take longer go the bleeding and pain to start o It is important for them to complete the same follow-up programme that is recommended for all medical abortions up to and including 10+0 weeks <10+0 w (when the first medication is administered) Interval treatment Mifepristone PO followed 24-48 hours later by misoprostol PO/PV or gemeprost PV o Misoprostol to be taken in the clinic or hospital but can have expulsion at home after they have taken the misoprostol 10+1w – 23+6w Anti D 200mg mifepristone PO followed 36-48h later by 800μg misoprostol PV or 600μg misoprostol given sublingually for women who decline PV misoprostol Follow the initial dose with 400μg doses of misoprostol (PV, sublingual or buccal) given every 3h until expulsion (max: 5) Special consideration after 21+ weeks Feticide (intracardiac KCl injection) should be given to eliminate the possibility of aborted foetus showing any signs of life 24+0 – 25+0 w Anti D 200mg mifepristone PO followed by 400 μg misoprostol every 3h until delivery 25+1 – 28+0 w Anti D 200mg mifepristone PO followed by 200 μg misoprostol every 4h until delivery >28+0 w Anti D 200mg mifepristone PO followed by 100 μg misoprostol every 6h until delivery * The uterus is more sensitive to misoprostol as pregnancy advances * RF for uterine rupture – pre-existing uterine scar, increased GA, multiparity

Answer 112

* Prophylactic abx * Anti-D <13 weeks – Vacuum aspiration – surgical dilation + suction of uterine contents • Involves gently dilating the cervix and using vacuum suction to evacuate the uterus • Can be performed under LA or GA • Cervix primed to make procedure easier • Prophylactic antibiotics (metronidazole) can be given to reduce the risk of infection >15 weeks – surgical dilation and evacuation of uterine contents or late medical abortion (induces “mini-labour”) • Required good cervical dilation to remove larger fetal parts • Extraction using aspiration + other instruments (e.g. forceps) • USS to confirm evacuation

Answer 113

• LA alone, conscious sedation with LA, deep sedation or GA o LA means they will be able to spend less time in hospital o IV sedation + LA will help if they are anxious about the procedure o With deep sedation or GA they will not usually be aware during the procedure o GA – IV propofol + short-acting opioid e.g. fentanyl rather than inhalational anaesthesia

Answer 114

* Softens + dilates cervix * Reduces the risk of incomplete abortion for women who are parous * Makes dilation easier for women who are parous or nulliparous * May cause bleeding + pain before the procedure <13+6w 400μg sublingual misoprostol given 1h before the abortion or 400μg PV misoprostol given 3h before the abortion or 200mg PO mifepristone 24-48h before abortion ``` 14+0 – 16+0w Consider cervical priming with osmotic dilators or buccal, sublingual, PV misoprostol or 200mg mifepristone, given the day before the abortion ``` 16+1 – 19+0w Osmotic dilators or Buccal, sublingual, PV misoprostol 19+1-23+6w 200mg PO mifepristone the day before the abortion and Insert osmotic dilators at the same time as mifepristone * Osmotic dilators inserted the day before the abortion * Do not offer misoprostol for cervical priming if the woman has had an osmotic dilator inserted the day before the abortion

Answer 115

Follow up and support after abortion Follow up after medical abortion up <10+0w • If expulsion at home – offer the choice of self-assessment, remote assessment, clinic follow-up • Provide them with a low sensitivity or multi-level urine pregnancy test to exclude an ongoing pregnancy • Advice women to seek support if they need it + how to access it o Support from family, friends or pastoral support o Peer support, support groups for women who have had an abortion o Counselling or psychological interventions • Discuss contraception o With all TOP patients discuss the insertion of long-acting reversible contraception (e.g. copper IUD, LNG-IUS, Nexplanon) o Contraceptive implant should be offered the day of the surgical abortion or the day they take mifepristone o Intrauterine methods should be offered at the same time as surgical abortion or asap after expulsion of pregnancy for medical abortions o DMPA IM injection for contraception can be provided at the same appointment as when they take mifepristone but having the injection at this stage may increase the risk of ongoing pregnancy, although the overall risk is low • Other things to discuss o No medical need for follow-up after uncomplicated abortion o No effect on future reproductive potential or ectopic pregnancy o What to expect  Women may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure.  Do pregnancy test 3 weeks after to confirm completion  With all abortion patients, discuss the insertion of long-acting reversible contraception (e.g. copper IUD, LNG-IUS, Nexplanon)  Suggest counsellor if indicated o Safety net: heavy bleeding (RPC), severe pain, smelly vaginal discharge, fever; ongoing signs of pregnancy (nausea or sore breasts), damage to cervix/ uterus/ etc. shoulder tip pain, mental health

Answer 116

``` o Complications of TOP:  N, V, D due to PGs – occasional but transient  Significant bleeding (1:1000)  Genital tract infection (5-10%)  Surgical TOP • Uterine perforation (1-4:1000) • Cervical trauma (1:1000) • Failed TOP (2.3:1000) • Haemorrhage • Infection  Medical TOP • Uterine rupture – mid-trimester medical TOP (<1:1000) • Failed TOP (1-14:1000)  RPC  Psychological sequelae – short-term anxiety, depressed mood  Long-term regret + concern about future fertility ```

Answer 117

* Consider if no symptoms/signs of ectopic * Explain that there is a small chance of ectopic pregnancy  follow-up appointments needed to ensure that the pregnancy has been terminated + to monitor for ectopic pregnancy * Provide 24h emergency contact details + advise them to get in contact immediately if they develop sx of ectopic pregnancy

Gynaecology - Management Flashcards

(141 cards)