Gyne Flashcards

Question

Staging of Endometrial Cancer:

Answer 1

Stage I: Confined to the uterus. ’ Stage II : Uterus & cervix. ’ Stage III: Uterus ,adnexia ,vagina,pelvic ,aortic lymph nodes involvement. ’ Stage IV : Bladder ,rectum, inguinal lymph nodes Distant metastasis: liver , lung

Answer 2

History; *Clinical presentation: Postmenopausal bleeding ’ Peri-menopausal bleeding ’ inter-menstrual bleeding ’ Abnormal bleeding with history of ’ anovulation Clinical presentation Postmenopausal women with endometrial cells on Pap Thickened endometrial stripe via sonography It is atypia that is the defining feature of the premalignant endometrial lesion. * Risk factors: PCO, D.M, H.T, Null party. ’ Physical exam. ’ General , abd.exam., pelvic exam. ’ Investigations: ’ U/S: Trans-vaginal U/S: ’ Endometrial thickness more than 4mm in menopausal woman. ’ Endometrial biopsy: ’ with or without hysteroscopy should be performed 1st investigations to order • Pelvic (transvaginal) ultrasound • Outpatient endometrial biopsy (with or without outpatient hysteroscopy) and histopathology • Hysteroscopy, dilation and curettage (D&C), and histopathology • Pap smear Investigations to consider • serum CA-125 level • saline infusion sonohysterogram • urea and creatinine (renal function testing) • LFTs ’ More investigations to consider ’ CXR to rule out pulmonary metastasis. Mammogram. Colon evaluation. Both breast and colon cancer are more ’ common in women with Endometrial CA, therefore should be screened for these diseases prior to surgical treatment .

Answer 3

1.Endometrial CA: Endometrial biopsy is the main diagnostic tool , 15% of the post-menaposal women with abnormal bleeding will be diagnosed as malignancy. 2. hormone replacement induced bleeding. 3.vaginal or uterine bleeding from atrophy 4. benign condition of endometrial hyperplasia, or polyps or fibroid induced bleeding. 5. other genital tract lesions and malignancies (cervical, vaginal, vulvar) ’

Answer 4

Treatment depend on: ’ stage IA endometrioid carcinoma not considering fertility preservation ’ stage IA endometrioid carcinoma considering fertility preservation ’ stage IB or II endometrioid carcinoma ’ stages III to IV endometrioid carcinoma; all non-endometrioid carcinomas (high risk) Treatment : Stage I low risk: TAH+BSO Stage I High risk: TAH+BSO –Post op. Radiation Stage II : TAH+BSO –Post op. Radiation Stage III: TAH +BSO +Post. op. Radiation Stage IV: Radiation For uterine sarcoma TAH +BSO +Radiation. The mainstay of adjuvant therapy for Endo.CA is Radiation Radiation may be delivered as either vaginal brachy-therapy or whole pelvic tele-therapy or both. Hormonal therapy, with progestins, and cytotoxic chemotherapy are generally reserved for advanced disease or recurrent disease. Prognosis: ’ ’ ’ ’ ’ Disease free 5 year survival is: > 90% for stage I, ~85% for stage II and ~45% for stage III carcinomas 10 - 30% of patients present at advanced stage (FIGO stage III - IV) Nodal metastases are most common to pelvic and paraaortic nodes; metastases also occur to bone, brain, liver, lung, skin Most recurrences are local (vaginal vault, pelvis)

Answer 5

History: Age, parity.  Severity and quantity of urine loss and frequency of incontinence episodes  Duration of the complaint .  Triggering factors or events ( cough, sneeze, lifting, bending, feeling of urgency)  Associated frequency, urgency, dysuria &UTI.  Any associated faecal incontinence or pelvic organ prolapse  Obstetrical history:  grand-multiparty,difficultdeliveries, forceps delivery , and large babies.  History of hysterectomy , or pelvic floor surgery.  Lifestyle issues as smoking or caffeine abuse.  Any medications. Medical problems :Chronic cough  Chronic obstructive pulmonary disease (COPD)  Congestive heart failure  Diabetes mellitus  Connective tissue disorders  Postmenopausal hypo-estrogenism.  Urinary tract stones  Physical Examination:  Height, weight. Obesity is a contributor to SUI influence therapy. Bp, PR.  RS, CVS Exam.  Abd. Exam.  the flank and costo-vertebral angles tenderness, or the presence of surgical scars.  Pelvic exam. Type of UI.  Assessment of pelvic floor muscles and prolapse.  Neurologic examination.  Investigations:  Urine testing: - MSU,C&S. Symptoms of UTI with leucocytes &nitrate. Symptoms of UTI with no leucocytes&nitrate. No symptoms of UTI with leucocytes &nitrate U/S for Assessment of residual urine:  residual urine normally less than 50 mls.:  Indications: -symptoms of voiding problems. -recurrent UTI. - Palpable bladder after voiding.  Bladder diaries: assessed at least for 3 days.  Pad test. Not recommended in routine assessment. Urodynamic study: Not recommended before start conservative treatment.  Urodynamic testing, as indicated:  Cystometry. Subtracted cystometry Urodynamicstudies : They are means of evaluating the pressure-flow relationship between the bladder and the urethra for defining the functional status of the lower urinary tract.   It aids in the diagnosis of urinary incontinence based on patho-physiology. It assess both the filling-storage phase and the voiding phase of bladder and urethral function

Answer 6

Conservative management:  1- Life style intervention:  A trial of caffeine reduction.  Modification of fluid intake.  Weight loss if BMI more than 30. Stress incontinence Therapy : 2- Physical therapy: Pelvic floor physiotherapy.  Pelvic Floor Muscle Training (PFMT):(more than 3 ms)  It should be offered to all women as first-line management and is effective for both stress and urge UI . If brief verbal instruction on PFM contractions is adequate in 78% of women .  Vaginal cones ,electrical stimulation. Anti-incontinence devices.  Absorbent Products are pads or garments designed to absorb urine to protect the skin and clothing. By reducing wetness and odour, they help to keep patients comfortable and allow them to function in usual activities. 3- Drug therapy: Imipramine (Tofranil): It facilitates urine storage by decreasing bladder contractility and increasing outlet resistance. It has an alpha-adrenergic effect on the bladder neck, an antispasmodic effect on the detrusor muscle, and a local anesthetic effect on the bladder mucosa  Duloxetine:  It’s serotonin/nor-adrenaline reuptake inhibitor It is approved for the treatment of stress incontinence in Europe, enhance urethral activity. Dose 20-40 mg. Urethral bulking agent: It is a substance that can be injected into the walls of the urethra. This increases the size of the urethral walls and allows the urethra to stay closed with more force like collagen, or autologoussubstances .More recently, investigations stem cell injections. It can be transurethral and per-urethral injection. Surgery for stress incontinence: x elevation . Surgery minimally invasive surgery may be the most effective form of managing urinary incontinence  Tape procedures A piece of plastic tape is inserted through an incision inside the vagina and threaded behind the urethra. The middle part of the tape supports the urethra, and the two ends are threaded through two incisions in either the:  tops of the inner thigh – this is called a transobturator tape procedure (TOT)  abdomen – this is called a retropubic tape procedure or tension-free vaginal tape procedure (TVT) Surgery:  Colpo-suspension:  Sling procedures: Abdominal. Laparoscopic. Abdominal-vaginal. Vaginal. Urge incontinence Treatment: Changes in diet habits. behavioural modification(Bladder Re-training). pelvic-floor exercises. medications : Anti-cholinergic Drugs  Oxybutynin : It reduces incontinence episodes by 83-90%. The total continence rate reported to be 41-50%.  Tolterodine (Detrol): It is a potent anti-muscarinicagent for treating detrusorover activity. The dosage range is 1-2 mg twice daily. New forms of surgical intervention:  Botulinum toxin  It s use in patients with neurologic conditions who have overactive bladder. Intra-detrusor injections via cystoscopy  Mixed incontinence : Anti-cholinergic drugs and surgery

Answer 7

Urinary Fistula:( True Incontinence) Constant feeling of wetness without sensation of urine leakage. Vesico -vaginal F. Uretero -vaginal fistulas are the most feared complications of female pelvic surgery. More than 50% of such fistulas occur after hystrectomy for benign diseases as uterine fibroids, menstrual abnormalities, and uterine prolapse. The incidence of vesico-vaginal fistula is unknown. The incidence of vesico-vaginal F. resulting from hysterectomy is estimated to be less than 1%.  In USA, more than 50% of vesicovaginal and ureterovaginal F. occur after hysterectomy for benign diseases.  Pelvic radiation is the primary cause of delayed fistula. Radiation is used to treat cervical or endometrial carcinoma .  In developing countries, obstetrical complications are the most common cause .  In cases of longstanding and obstructed labour leading to pressure necrosis on the anterior vaginal wall. It may be large and have extensive local tissue damage and necrosis. Diagnosis: History. Constant feeling of wetness without sensation of urine leakage Ph. examination : PV , any fluid collection noted. Investigations: Discharge can be tested for urea, creatinine, or potassium concentration to determine VVF.  Indigo carmine dye can be given intravenously and if the dye appears in the vagina, a fistula is confirmed.  Three swab test: By filling of the bladder with methylene blue and use cotton in three sites in the vagina  Colour Doppler ultrasonographywith contrast media of the urinary bladder may be considered .  Cysto-urethroscopymay be performed.  If ureteric involvement is suspected then IVP performed.  The differential diagnosis for the discharge of urine vesico-vaginal F. ,or Vaginitis.  Urine should be sent for culture and sensitivity, and infection should be treated. >discovered immediatly-> TX courgical immedially Treatment: > If discovered > Uretro Vaginal - after remote time -> Conservative TX -> Tx immediately (surgery) - > re-implant the Wreter  Vesico-vaginal and Uretero-vaginal fistulas recognized within 3-7 days after the causative operation may be repaired immediately via a trans-abdominal or trans-vaginal approach.  Fistulas identified after 7-10 days postoperatively should be monitored periodically until all signs of inflammation and indurations have resolved.  The traditional approach has been to wait at least 3-4 months before fistula closure.  Some they close the fistula with or without using peritoneal flap without waiting 3-4 months.  Patients with a history of multiple failed repairs, patients with associated enteric fistula or patients with a history of pelvic radiation should not undergo fistula repair for at least 6-8 months. For a small fistula, an initial trial of urethral catheter drainage may be attempted for 4-6 weeks. Optimal success achieved in patients who had longer and narrower fistulas. . Persistent incontinence after an adequate period of watchful waiting requires open exploration and formal fistula repair.  The trans-vaginal approach is the safest and most comfortable for the patient.  A history of previous failed repairs does not preclude trans-vaginal reconstruction.  Fistulas occurring after hysterectomy are usually amenable to trans-vaginal reconstruction.  Trans-vaginal repairs do not require excision of the fistula tract.

Answer 8

Confirmed risk factors: ’ ’ ’ ’ ’ Increasing age: risk doubles with each decade of life. Vaginal delivery. Increasing parity. Overweight (BMI 25-30) and obesity (BMI >30). Spina bifida and spina bifida occulta. ’ Possible risk factors: ’ Intrapartum Factors (controversial and unproven):  Fetal macrosomia.  Prolonged second stage of labour.  Epsiotomy.  Anal sphincter injury.  Epidural anaesthesia.  Use of forceps.  Use of oxytocin. Age <25 years at first delivery. ’ ’ ’ ’ ’ Race. Family history of prolapse. Constipation. Connective tissue disorders, eg Marfan's syndrome, Ehlers-Danlos syndrome. Previous hysterectomy.

Answer 9

Anterior compartment prolapse ’ Urethrocele: prolapse of the urethra into the vagina. Frequently associated with urinary stress incontinence. ’ Cystocele: ’ and prolapse of the bladder into the vagina. large cystocele may cause increased urinary frequency, frequent urinary infections and produce a pressure sensation or mass at the introitus. Cystourethrocele: prolapse of both urethra bladder. A ’ Middle compartment prolapse ’ Uterine prolapse: descent of the uterus into the vagina. ’ Vaginal vault prolapse: descent of the vaginal vault post-hysterectomy. Often associated with cystocoele, rectocele, and enterocele. With complete inversion, the urethra, bladder, and distal ureters may be included resulting in varying degrees of retention and distal ureteric obstruction. procedencia third degree uterine prolapse ’ Enterocele: herniation of the pouch of Douglas (including small intestine/omentum) into the vagina. ’ Can occur following pelvic surgery. Can be difficult to differentiate clinically from rectocele but a cough impulse can be felt in enterocele on combined rectal and vaginal examination. ’ ’ Rectocele: prolapse of the rectum into the vagina. Cysto-urethrocele is the most common type of prolapse, followed by uterine prolapse and then rectocele. Urethroceles are rare.

Answer 10

1st degree: cervix visible when the perineum depressed -it is contained within the vagina. 2nd degree: cervix prolapsed through the introits with the fundus remaining in the pelvis. 3rd degree: procidentia (complete prolapse) uterus is outside the introits. is - entire

Answer 11

Diagnosis is usually clinical and based on history and examination. If there are urinary symptoms consider the following: Urinalysis ± a mid-stream specimen of urine (MSU). Post-void residual urine volume testing using a catheter or bladder ultrasound scan.  Urodynamic investigations: ’    If  Cystometry. Urea and creatinine. Renal ultrasound scan. there are bowel symptoms consider : Anal manometry.

Answer 12

Management : ’ ’ ’ ’ ’ ’ ’ ’ ’ It depends on : Age , desire for childbearing, symptoms & Associated factors. the woman's preferences site of prolapse lifestyle factors comorbidities, including cognitive or physical impairments previous abdominal or pelvic floor surgery benefits and risks of individual procedures ’ ’ ’ ’ ’ ’ ’ Management: Options of treatment: Conservative treatment. Watchful waiting. Vaginal pessary insertion. Surgery. No treatment is necessary if incidental asymptomatic mild prolapse is found. There is no evidence about how to treat these women. ’ Conservative treatment options:  Lifestyle modification:  • losing weight, if the woman has a BMI greater than 30 kg/m2  • minimizing heavy lifting  • preventing or treating constipation. treatment of cough, smoking cessation Pelvic floor muscle exercises: ’ When the pelvic floor muscles work well, they hold the bladder, bowel, and vagina in the right position, and pelvic floor exercises can help women with mild to moderate prolapse ’ There is no definite evidence for the benefit of pelvic floor muscle exercises in the management of uterine prolapse  . It may be beneficial as primary therapy for early stages of uterine prolapse.  Vaginal oestrogen creams: some advocate a trial of topical oestrogen cream for 4-6 weeks if prolapse is mild but there is no current evidence of any benefit. Consider vaginal oestrogen for women with pelvic organ prolapse and signs of vaginal atrophy. ’ Vaginal pessary insertion: A good alternative to surgery. ’ Inserted into the vagina to reduce the prolapse, provide support and relieve pressure on the bladder and bowel. ’ Made of silicone or plastic. Pessaries are effective: ’ - As a test if symptoms due to prolapse. ’ - If pregnancy planned.  For short-term relief of prolapse prior to surgery.  In the long term if surgery is not wanted or is contra-indicated. ’ Fitting a pessary:  Ensure the patient's bladder and bowel are empty  Perform a bimanual examination and estimate the size of the vagina.  The aim is to fit the largest pessary that does not cause discomfort.  Ask the patient after insertion to walk around, bend and micturate to ensure that the pessary is retained. Describe Complications ’ including vaginal discharge, bleeding, difficulty removing pessary and pessary expulsion ’ explain that the pessary should be removed at least once every 6 months to prevent ’ serious pessary complications. ’ Surgery ’ Surgery is very effective. ’ Indications for surgery are: ’ failure of pessary. ’ patient who wants definitive treatment. ’ prolapse combined with urinary or faecal incontinence. ’ Urinary incontinenc may be masked by prolapse and can be precipitated by surgery. ’ Some operations, eg colposuspension for a cystourethrocele, may predispose to a prolapse in another compartment. ’ The choice of procedure will depend on: ’ whether the woman is sexually active. ’ Not complete family. ’ the fitness of the patient. ’ and surgeon's preference. ’ Types of Surgery: ’ Vaginal Operation: ’ Ant., Post. Repair, Vag. Hysterectomy. ’ TVT, TOT. ’ Abdominal : ’ Laparoscopic. ’ Colpo-suspension, sling operations. ’ Oblitrative: ’ Post operative Advices: ’ If the prolapse remains corrected and the patient conceives, an elective Caesarean section may be advisable. ’ Generally women should avoid heavy lifting after surgery and avoid sexual intercourse for 6-8 weeks. ’ Surgery for bladder/urethral prolapse ’ Anterior colporrhaphy: involves central plication of the fibro-muscular layer of the anterior vaginal wall. Mesh reinforcement may be used. Performed trans-vaginally. - Intra-operative complications are uncommon but haemorrhage, haematoma, and cystotomy may occur. Colposuspension: performed for urethral sphincter incontinence associated with a cystourethrocele. The paravaginal fascia on either side of the bladder neck and the base of the bladder are approximated to the pelvic side wall by sutures placed through the ipsilateral iliopectineal ligament. ’ Surgery for uterine prolapse ’ Hysterectomy: a vaginal hysterectomy has the advantage that no abdominal incision is needed, thereby reducing pain and hospital stay. This can be combined with anterior or posterior colporrhaphy. ’ Abdominal or laparoscopic sacrohysteropexy: performed if the woman wishes to retain her uterus. The uterus is attached to the anterior longitudinal ligament over the sacrum. Mesh is used to hold the uterus in place. Sacrospinous fixation: unilateral or bilateral fixation of the uterus to the sacrospinous ligament. Performed via vaginal route. Lower success rate than sacrohysteropexy. Risk of injury to pudendal nerve and vessels and sciatic nerve. ’ Surgery for rectocele/enterocele ’ Posterior colporrhaphy: involves levator ani muscle plication or by repair of discrete fascial defects. A mesh can be used for additional support. Performed transvaginally. Levator plication may lead to dyspareunia. ’ There are currently two main types of surgery available to repair apical prolapse: colpocleisis and sacrospinous fixation. ’ Obliterative surgery ’ ’ ’ ’ off Corrects prolapse by moving the pelvic viscera back into the pelvis and closing the vaginal canal. Known as colpocleisis. Vaginal intercourse is no longer possible. Advantages are that it is almost 100% effective in treating prolapse and has a reduced perioperative morbidity. Not commonly carried out in Europe.

Answer 13

Diagnosis Diagnosis of APS requires the presence of at least 1 of the clinical criteria and at least 1 of the laboratory criteria . The clinical criteria include the following: - Vascular thrombosis - 3 or more consecutive unexplained miscarriages - At least 1 unexplained death of a morphologically normal fetus at or after 10 weeks' gestation - At least 1 premature birth of a morphologically normal neonate at or before 34 weeks' gestation, associated with severe preeclampsia or severe placental insufficiency The laboratory criteria include the following: -aCL: Immunoglobulin G (IgG) and/or immunoglobulin M (IgM) isotype is present in medium or high titer on 2 or more occasions, 6 or more weeks apart -Demonstration of a prolonged phospholipid-dependent coagulation on screening tests (eg, activated partial thromboplastin time, clotting time, prothrombin time) -Failure to correct the prolonged screening test result by mixing with normal platelet-poor plasma -Shortening or correction of the prolonged screening test result with the addition of excess phospholipids -Exclusion of other coagulopathies as clinically indicated (eg, factor VIII inhibitor) and heparin Management Treatment options for APS include the following: Subcutaneous heparin, Low-dose aspirin, Prednisone, Immunoglobulins and Combinations of these therapies

Answer 14

Cervical insufficiency (cervical incompetence) is defined as the inability of the uterine cervix to retain a pregnancy in the second trimester, in the absence of uterine contractions. the following indications for cervical cerculage: History of second trimester pregnancy loss with painless cervical dilatation Prior cerculage placement for cervical insufficiency History of spontaneous preterm birth (prior to 34 weeks’ gestation) and a short cervical length (ie, < 25 mm) prior to 24 weeks’ gestation Painless cervical dilatation on physical examination in the second trimester Signs and symptoms The diagnosis of cervical insufficiency is primarily based on a history of a previous midtrimester pregnancy loss, which can present with the following: Painless cervical dilatation and bulging fetal membranes upon presentation in the second trimester of pregnancy Preterm premature rupture of membranes (PPROM) Rare or absent uterine contractions In women without a history of pregnancy loss, the diagnosis of cervical insufficiency is based on a combination of the following: Clinical presentation, Physical examination &Ultrasonographic findings Most patients are asymptomatic, but some may present with any the following symptoms: Pelvic pressure , Cramping , Back pain , Increased vaginal discharge Diagnosis Although the diagnosis of cervical insufficiency may be based on a history of midtrimester pregnancy loss, the following measures may also be useful: Ultrasonographic transvaginal measurement of cervical length – Cervical length has a strong inverse correlation with the risk of spontaneous preterm birth, particularly in women with a history of preterm delivery Fetal fibronectin (fFN) testing – Studies have demonstrated the utility of fFN testing in addition to cervical length assessment, with a significant improvement in the prediction of preterm delivery in women with a positive fFN and a cervical length of less than 25 mm Management The mainstay of surgical treatment for cervical insufficiency is cervical cerclage, which is reasonable in the following situations: 1-History of second trimester pregnancy loss with painless cervical dilatation 2-Prior cerclage placement for cervical insufficiency 3-History of spontaneous preterm birth (prior to 34 weeks’ gestation) and a short cervical length (ie, < 25 mm) prior to 24 weeks’ gestation 4-Painless cervical dilatation on physical examination in the second trimester Cerclage can be accomplished either TV or transabdominally. Cerclage is usually done TV as either a McDonald or Shiradkor procedure. When these 2 procedures are unsuccessful or difficult to perform, the transabdominal cerclage procedure is done . RH status:-AntiD is required in the following circumferences for nonsensitized Rh negative women . 1-Spontaneous miscarriage 12 wk & more . 2-At any GA with surgical or medical intervention 3-At any GA with repeated severe bleeding .

Answer 15

Risk factors Multiple factors contribute to the relative risk of ectopic pregnancy. In theory, anything that hampers or delays the migration of the fertilized ovum (blastocyst) to the endometrial cavity can predispose a woman to ectopic gestation. The following risk factors have been linked to ectopic pregnancy: 1- Pelvic inflammatory disease A history of major tubal infection decreases fertility and increases abnormal implantation. The most common cause of PID is an antecedent infection caused by Chlamydia trachomatis. Patients with chlamydial infection have a range of clinical presentations, from asymptomatic cervicitis to salpingitis and florid PID. More than 50% of women who have been infected are unaware of the exposure. Other organisms that cause PID, such as Neisseria gonorrhea, also increase the risk of ectopic pregnancy, and a history of salpingitis increases the risk of ectopic pregnancy 4-fold. The incidence of tubal damage increases after successive episodes of PID (ie, 13% after 1 episode, 35% after 2 episodes, 75% after 3 episodes). 2- History of previous ectopic pregnancy After 1 ectopic pregnancy, a patient incurs a 7- to 13-fold increase in the likelihood of another ectopic pregnancy. 3- History of tubal surgery and conception after tubal ligation Previous tubal surgery has been demonstrated to increase the risk of developing ectopic pregnancy such as fimbrioplasty, tubal reanastomosis, and lysis of peritubal or periovarian adhesions. 4- Smoking Cigarette smoking has been shown to be a risk factor for ectopic pregnancy development. Studies have demonstrated an elevated risk ranging from 1.6 to 3.5 times that of nonsmokers. A dose-response effect has also been suggested. 5- Use of oral contraceptives or an intrauterine device All contraceptive methods lead to an overall lower risk of pregnancy and therefore to an overall lower risk of ectopic pregnancy. However, among cases of contraceptive failure, women at increased risk of ectopic pregnancy compared with pregnant controls included those using progestin-only oral contraceptives, progestin-only implants, or IUDs and those with a history of tubal ligation . Nevertheless, if a woman ultimately conceives with an IUD in place, it is more likely to be an ectopic pregnancy. 6- Use of fertility drugs or assisted reproductive technology Ovulation induction with clomiphene citrate or injectable gonadotropin therapy has been linked to a 4-fold increase in the risk of ectopic pregnancy in a case-control study. This finding suggests that multiple eggs and high hormone levels may be significant factors. In addition, the risk of ectopic pregnancy and heterotopic pregnancy (ie, pregnancies occurring simultaneously in different body sites) dramatically increases when a patient has used assisted reproductive techniques—such as such as in vitro fertilization (IVF) . 7- Increasing age The highest rate of ectopic pregnancy occurs in women aged 35-44 years. A 3- to 4-fold increase in the risk of developing an ectopic pregnancy exists compared with women aged 15-24 years. One proposed explanation suggests that aging may result in a progressive loss of myoelectrical activity in the fallopian tube; myoelectrical activity is responsible for tubal motility. 8- Salpingitis isthmica nodosum Salpingitis isthmica nodosum is defined as the microscopic presence of tubal epithelium in the myosalpinx or beneath the tubal serosa. These pockets of epithelium protrude through the tube, similar to small diverticula. The etiology of salpingitis isthmica nodosum is unclear, but proposed mechanisms include postinflammatory and congenital changes, as well as acquired tubal changes, such as those observed with endometriosis 9- Other Other risk factors associated with increased incidence of ectopic pregnancy include anatomic abnormalities of the uterus such as a Tshaped or bicornuate uterus, fibroids or other uterine tumors, previous abdominal surgery, failure with progestin-only contraception, and ruptured appendix.

Answer 16

Diagnosis 1----Serum β-HCG levels In a normal pregnancy, the β-HCG level doubles every 48 hours until it reaches 10,000-20,000mIU/mL. In ectopic pregnancies, β-HCG levels usually increase less. Mean serum β-HCG levels are lower in ectopic pregnancies than in healthy pregnancies. No single serum β-HCG level is diagnostic of an ectopic pregnancy. Serial serum β-HCG levels are necessary to differentiate between normal and abnormal pregnancies and to monitor resolution of ectopic pregnancy once therapy has been initiated. The discriminatory zone of β-HCG :- the level above which an imaging scan should reliably visualize a gestational sac within the uterus in a normal intrauterine pregnancy) is as follows: 1500-1800 mIU/mL with transvaginal ultrasonography, but up to 2300 mIU/mL with multiple gestates , 6000-6500 mIU/mL with abdominal ultrasonography. Absence of an intrauterine pregnancy on a scan when the β-HCG level is above the discriminatory zone represents an ectopic pregnancy or a recent abortion. 2----Ultrasonography Ultrasonography is probably the most important tool for diagnosing an extrauterine pregnancy. Transvaginal ultrasonography, or endovaginal ultrasonography, can be used to visualize an intrauterine pregnancy by 24 days postovulation or 38 days after the last menstrual period (about 1 week earlier than transabdominal ultrasonography). An empty uterus on endovaginal ultrasonographic images in patients with a serum β-HCG level greater than the discriminatory cut-off value is an ectopic pregnancy until proved otherwise. Color-flow Doppler ultrasonography improves the diagnostic sensitivity and specificity of transvaginal ultrasonography, especially in cases in which a gestational sac is questionable or absent. 3----Laparoscopy Laparoscopy remains the criterion standard for diagnosis; however, its routine use on all patients suspected of ectopic pregnancy may lead to unnecessary risks, morbidity, and costs. Moreover, laparoscopy can miss up to 4% of early ectopic pregnancies. Laparoscopy is indicated for patients who are in pain or hemodynamically stable. 4---Culdocentesis Aspiration of peritoneal fluid from posterior vaginal pouch (haemoperitonial fluid )

Answer 17

Management :- Therapeutic options in ectopic pregnancy are as follows: 1- Expectant management 2- Medical management 3- Surgery Expectant management::-Candidates for successful expectant management should be -asymptomatic and have no evidence of rupture or hemodynamic instability. -Low serum HCG < 1500 IU/L -Candidates should demonstrate objective evidence of resolution (eg, declining β-HCG levels).Close follow-up and patient compliance are of paramount importance, as tubal rupture may occur despite low and declining serum levels of β-HCG. Medical management::--Local injection of PG , potassium chloride , hyperosmolar glucose or methotrexate . Methotrexate is the standard medical treatment for unruptured ectopic pregnancy. A single-dose IM injection is the more popular regimen. The ideal candidate should have the following: 1- Hemodynamic stability 2-No severe or persisting abdominal pain 3-The ability to follow up multiple times 4-Normal baseline liver and renal function test results 5-Mass size < 5 cm . 6-Serum HCG < 3000 IU/L 7-NO evidence of cardiac activity . Absolute contraindications to methotrexate therapy include 1- Existence of an intrauterine pregnancy 2- Immunodeficiency 3- Moderate to severe anemia, leukopenia, or thrombocytopenia 4- Sensitivity to methotrexate 5- Active pulmonary or peptic ulcer disease 6- Clinically important hepatic or renal dysfunction 7- Breastfeeding 8- Evidence of tubal rupture Surgical treatment::-- Laparoscopy has become the recommended surgical approach in most cases. Laparotomy is usually reserved for patients who are 1--hemodynamically unstable 2--patients with cornual ectopic pregnancies; 3--preferred method for surgeons inexperienced in laparoscopy 4--patients in whom a laparoscopic approach is difficult such as morbid obesity and adhesion . Salpengectomy (best) or salpengestomy ( if contralateral tube is unhealthy ) Fertility following ectopic pregnancy Previous history of infertility has been found to be the most significant factor affecting postsurgical fertility when the contralateral fallopian tube is normal, the subsequent fertility rate is independent of the type of surgery. Intrauterine pregnancy rate following ectopic pregnancy between 50-70% . Recurrent ectopic pregnancy occur in 6-16 % of women with previous history of ectopic .

Answer 18

Threatened miscarriage don't bleeding severityof slight sever or > - < missed > accidentally discovered severity , after exclusion & => .S T= = indicate of Condition of other causes of lower abdominal pain => Threatened miscarriage. 24hrs > - 2nd /1's., first S1%& Trimester Vaginal bleeding, abdominal/pelvic pain of any degree, or both during early pregnancy represents a threatened miscarriage. Approximately a fourth of all pregnant women have some degree of vaginal bleeding during the first 2 trimesters. About half of these cases progress to an actual miscarriage. Bleeding and pain accompanying threatened miscarriage is usually not very intense. Threatened miscarriage rarely presents with severe vaginal bleeding. On vaginal examination, the internal cervical os is closed and no cervical motion tenderness or tissue is found. Diffuse uterine tenderness, adnexal tenderness, or both may be present. Threatened miscarriage is defined by the absence of passing/passed tissue and the presence of a closed internal cervical os. These findings differentiate threatened miscarriage from later stages of a miscarriage. presented emergency like pain bleeding 9 - 14 Weeks > to exam with sever lower abd - on pelvic whole > within hours => > UIS => open of (gestational pain . products in labour lower Uterine + Segment) & gestational Sac in the Uterns Inevitable miscarriage > - progress to complete or positive FHR incompetite miscarriage + with or without intervention . > can be accelerated by giving oxytocic agent . Vaginal bleeding is accompanied by dilatation of the cervical canal. Bleeding is usually more severe than with threatened miscarriage and is often associated with abdominal pain and cramping. On examination : open os part of gestational products outside the uterus part inside ↳ most exam sever one heavy bleeding an tachycardia the due fainting < VIS => + Incomplete miscarriage > by pelvic > MgX > - , open At first ABC => os > Need urgent evacuation of uterus and retained placental piece (Currtages , Under GA or local Vaginal bleeding may be intense and accompanied by abdominal pain. xytocic + · again en > mesoprostol The cervical os may be open with products of conception being passed, or the internal cervical os may be closed. Ultrasonography is used to reveal whether some products of conception are still present in the uterus. make contract To the uterus + - close > I bleeding the OS Closed > OS Complete miscarriage Patients may present with a history of bleeding, abdominal pain, and tissue passage. By the time the miscarriage is complete, bleeding and pain usually have subsided. Ultrasonography reveals an empty uterus. Diagnosis may be confirmed by observation of the aborted fetus with the complete placenta.

Answer 19

Chronic maternal health factors include the following: • Maternal insulin-dependent diabetes mellitus (IDDM): As many as 30% of pregnancies in women with IDDM result in spontaneous miscarriage, predominantly in patients with poor glucose control in the first trimester. • Severe hypertension • Renal disease • Systemic lupus erythematosus (SLE) • Hypothyroidism and hyperthyroidism Acute maternal health factors include the following: • Infections (eg, rubella, cytomegalovirus [CMV], and mycoplasmal, ureaplasmal, listerial, toxoplasmal infections) • Trauma Severe emotional shock may also cause first- and second-trimester miscarriages. Other factors that may contribute to miscarriage Exogenous factors include the following: • Alcohol • Tobacco • Cocaine and other illicit drugs Anatomic factors include the following: Congenital or acquired anatomic factors are reported to occur in 10-15% of women who have recurrent spontaneous miscarriages. • Congenital anatomic lesions include müllerian duct anomalies (eg, septate uterus, diethylstilbestrol [DES]-related anomalies). Müllerian duct lesions usually are found in second-trimester pregnancy loss. • Anomalies of the uterine artery with compromised endometrial blood flow are congenital. • Acquired lesions include intrauterine adhesions (ie, synechiae), leiomyoma, and endometriosis. • Other diseases or abnormalities of the reproductive system that may result in miscarriage include congenital or acquired uterine defects, fibroids, cervical incompetence, abnormal placental development Endocrine factors include the following: • Endocrine factors potentially contribute to recurrent miscarriage in 10-20% of cases. • Luteal phase insufficiency (ie, abnormal corpus luteum function with insufficient progesterone production) is implicated as the most common endocrine abnormality contributing to spontaneous miscarriage. • Hypothyroidism, hypoprolactinemia, poor diabetic control, and polycystic ovarian syndrome are contributive factors in pregnancy loss. Infectious factors include the following: • Presumed infectious etiology may be found in 5% of cases. • Bacterial, viral, parasitic, fungal, and zoonotic infections are associated with recurrent spontaneous miscarriage. Immunologic factors include the following: • Immunologic factors may contribute in up to 60% of recurrent spontaneous miscarriages. • Both the developing embryo and the trophoblast may be considered immunologically foreign to the maternal immune system. • Antiphospholipid antibody syndrome generally is responsible for more second-trimester pregnancy losses than first-trimester losses. • Miscellaneous factors • Miscellaneous factors may account for up to 3% of recurrent spontaneous miscarriages. Other contributing factors implicated in sporadic and recurrent spontaneous abortions include environment, drugs, placental abnormalities, medical illnesses, and male-related causes. Among the risk factors for early pregnancy loss are very low or very high body mass index, a history of previous miscarriages, smoking, alcohol use, working night shifts, air pollution, and exposure to pesticides.

Answer 20

Prognosis • The prognosis for a successful pregnancy depends upon the etiology of previous spontaneous miscarriages, the age of the patient, and the sonographic appearance of the gestation. • Correction of an endocrine abnormality in women with recurrent miscarriage has the best prognosis for a successful pregnancy (>90%). • In women with an unknown etiology of prior pregnancy loss, the probability of achieving successful pregnancies is 40-80%.

Answer 21

Treat all patients with vaginal bleeding of any etiology as follows: • Determine hemodynamic stability and treat instability. If the patient is in hemorrhagic shock, treatment includes the Trendelenburg position, oxygen, aggressive fluid resuscitation (at least 2 large-bore IV lines with lactated Ringer [LR] solution or normal saline, wide open), and hemotransfusion. • Determine pregnancy status (qualitative and quantitative). • Make laboratory determination of hematocrit (Hct) level and Rh status. • Perform a pelvic examination to determine the rate of bleeding; presence of blood clots or products of conception; and condition of cervical os, cervix, uterus, and adnexa. • Perform pelvic ultrasonography to determine intrauterine and/or extrauterine contents (fetal heart activity) and/or to clinically classify spontaneous miscarriage.

Answer 22

Missed miscarriage:-Treatment may vary depending on gestational age : • Expectant management:- within few weeks may aborted spontaneously (risk of DIC and septicemia) • medical management:- By using uterotonic therapy alone or in conjugation with antihormone therapy. The advantages of medical therapy is that no surgical procedures are needed if it is successful. Passage of tissue should happen within a few days of receiving medical therapy. If it is not successful, then a surgical approach may follow. The risks for medical therapy include bleeding, infection, possible incomplete abortion, and possible failure of the medication to work. The first tablet, mifepristone (ante progesterone) , will be taken by mouth. . If the patient start to bleed heavily and pass clots after taking this first tablet, there is no need for any further medication. If she is only spotting blood, continue with the second medicine, misoprostol (uterotonic agent). Insert misoprostol, into the vagina 36-48 hours after taking the mifepristone.postintravaginal misoprostol 400 mcg, whereas only 16.7% of women achieved this after 2 h of 600 mcg. The 600-mcg group had slightly greater adverse effects (eg, bleeding, abdominal pain, fever >38ºC).Dosage intended for cervical ripening can induce abortion in some patients. Oral doses of 100-400 mcg can be combined with vaginal insertion of prostaglandins to enhance cervical dilatation. primigravid women (6-11 wk gestation), 93.3% achieved dilatation of the cervix of 8 mm or greater after 3 h Surgical route:- evacuation of uterus by D&C under local or general anesthesia , cervical dilatation can be assumed by cervical priming agent such as PG agonist ( misoprostol ), at least 2 hr. before operation ,this reduce the pressure required for dilatation of the cervix & hence the risk of uterine perforation . The advantage of D&C is that the procedure is scheduled and occurs at a known time. Complications of D&C include Risk of GA, bleeding, Infection, Retained products, Uterine perforation & Asherman syndrome (intrauterine adhesion result from vigorous curettage)

Answer 23

in the more severe stages of endometriosis, there is commonly anatomical distortion, with periadnexal adhesions and destruction of ovarian tissue when endometriomas develop. A number of possible and variable mechanisms have been postulated to connect mild endometriosis with infertility including negative eﬀects on ovarian reserve, ovulation dysfunction, sperm survival in the female genital tract and egg quality (and thus embryo quality). Endometriosis and infertility • • • • • medical treatment of endometriosis does not improve fertility and should not be given to patients wishing to conceive. However, surgical ablation/excision of minimal and mild endometriosis does improve fertility chances. leave endometriomas alone prior to IVF unless they are symptomatic or reduce access for egg collection

Answer 24

Differential diagnosis 1-Adenomyosis (menorrhagia) 2-PID 3-CA.of colon or rectum 4- CA. of ovary 5- Pelvic congestion syn.

Answer 25

Staging: 9 American Fertility Society's Scoring System to classify endometriosis Stage 1 (minimal) = 1-5 Stage 2 (mild) = 6-15 Stage 3 (moderate) = 16-40 Stage 4 (severe) =>40

Answer 26

Diagnosis: 1-Clinical ﬁnings : is suggested by the clinical ﬁndings of thickening or nodularity of the uterosacral ligaments , tenderness . Endometriosis in the pouch of Douglas , an ovarian mass & a ﬁxed retroverted uterus . However, a speciﬁc diagnosis requires visualization & in uncertain cases , biopsy of lesions , either at laparoscopy or laparotomy . . 2- Non - invasive tests a-Ca 125 level : non - speciﬁc. b- ultrasound : is of limited value , helpful when there is endometriomas or chocolate cysts) . c- MRI : is of little beneﬁt also , useful when there are ovarian cyst , or invasion of surrounding organs such as bowel , bladder , recto vaginal septum 3- Laparoscopy: remains the gold standard means of diagnosing endometriosis . endometriotic lesions can be red, puckered, black ‘matchstick’ or appear white and ﬁbrous. Role of laproscopyis vital: a. provides direct visualization of endometriotic lesions . b. possibility to biopsy suspected areas . c. allow staging of the disease . d.It allow concurrent therapy at the time of laproscopy in the form of cautery or laser treatment in selected cases . d. Allow checking patency of fallopian tubes. A: Red lesions on peritoneum B: black ‘matchstick’lesions C: white fibrous lesion.

Answer 27

Surgical treatment Conservative or deﬁnitive. 1. Conservative surgery Through laproscopy or open surgery . By eradicate vissible endometriotic lesions with diathermy or laser . also endometrioma treated in 2 ways either the cyst opened & drained , & base lasered , or do ovarian cystectomy . lysis of tubo - ovarian adhesions or do salpingostomy . 2- Deﬁnitive (radical ) surgery : TAH & BSO indications a. severe symptomatology b.progressive disease . c.women whose families are complete . d. large adherent endometriotic cyst. e.patient with deep - seated endometriosis involving the bowel or bladder . so endometriosis remains a disorder of little hope of a perminant cure , & one with repeat recurrences throught the reproductive life . Malignant changes in endometriosis is very rare , usually involves ovarian endometriosis . it is either endometriod ca. or adenocanthoma. 1- Drug therapy: a. NSAID are helpful in reducing the severity of dysmenorrheal & pelvic pain . b. Hormone therapy: medical treatment of endometriosis aimed at the prevention of menstruation using sex steroids in various ways . oestrogens , androgens, progestogens , & combinations have been used . 1.COC use of continuous COC & in increasing dosage for up to 9 months to induce a state of pseudopregnancy ; with anovulation & amenorrhea , would lead to necrosis & absorptiopn of decidualized endometriosis . S/E weight gain , nausea , vomiting , breakthrough bleeding . 2-Danazole & Gestrinone : it is mild androgenic , antiprogestogenic , antigonadotrophic , immunosuppressive eﬀect , also has direct inhibition of endometrial cell growth, used in the past but are no longerv appropriate. Dose Danazole 400 -800 mg / day Gesrinone 2.5 mg twice weekly used in courses for 3 - 6 months . Side eﬀects androgenic S/E e.g. weight gain , greasy skin , acne, deepening of voice . longer - term administration may leads to alterations in lipid proﬁle , or liver function , which needs to be monitored . 3- progestogens such as medroxyprogesterone acetate or dydrogesterone . given on continuous basis and the levonorgestrel intrauterine system (LNG-IUS) (Mirena) . 4- GnRH agonists Temporary induction of pseudo - menopause . used as intranasal or subcutaneous routes or slow - release depot formulation for one month . S/E hot ﬂush , night sweats , atrophic vaginitis , long - term use may leads to osteoporosis . • a newer class of drug called aromatase inhibitors that inhibit the • action of the enzyme aromatase, which converts androgens into oestrogens and is over expressed in endometriotic tissue. • Further research needed to be used in refractory cases.

Answer 28

is a disorder in which endometrial glands & stroma are found deep within the myometrium. Predisposing factors 1. usu. occur in multiparous women ; repeated pregnancies may predispoes to extension of endometrium into the myometrium . 2. Age; in late thirties or early forties ( near the end of reproductive life ). 3. Vigorous curettage; may leads to damage of the uterine wall, thus allowing acess by the endometrium 4. Cystic glandular hyperplasia of the endometrium . 5. High socio - economic status Pathology uterus is usu. enlarged (symmetrical enlargement ) , lesion may be localized or diﬀuse . Clinical features the principal symptom is menorrhagia (perhaps from interference with normal uterine haemostatic mechanisms) , progressive secondary dysmenorrhea , pelvic discomfort , & dysparunnia. is diﬃcult pre -op. 1. Ultrasound; may be useful when adenomyosis is marked & localized to one area. 2. MRI • 3. Pathological examination of the hysterectomy specimen . where it is identiﬁed in 40% of uteri from a general female population of reproductive age. Treatment Conservative surgery & medical treatment poorly developed . Hysterctomy ; is the only deﬁnitive treatment .

Answer 29

1-inert devices such as lippes loop. 2-devices with various applications of copper designed to increase effectiveness & decrease surface area &so decrease side effects particularly the menorrhagia & dysmenorrheal e.g. copper T &7 & now Multiload & Nova T. 3-Medicated I.U.C.D releasing low concentrations of progesterone or norgestrel e.g • The 52 mg LNG-IUS (Mirena®) . 20 ug levonorgestrel /day & lasting for 5 years, advantage is menstrual blood loss is very substantially reduced 90% at 1 year. • and the 13.5 mg LNGIUS • (known as Jaydess) is licensed for 3 years for contraceptive use.

Answer 30

IUDs work by inhibiting fertilisation by direct toxicity . An inflammatory reaction within the endometrium can also have an antiimplantation effect. Copper is toxic to the ovum and the sperm and the copper content of the cervical mucus inhibits sperm penetration as well • . LNG-IUS works primarily by its effect on the endometrium, which prevents endometrial proliferation and implantation. Its progestogenic effect on thickening the cervical mucus also • impedes entry of sperm The LNG-IUS does not prevent ovulation. • The Cu-IUD duration of use is between 3 and 10 years, depending on the device used and age of woman at insertion. If a woman has a CuIUD inserted at 40 years or above, it can be left in situ until the menopause. • For women who have a 52 mg LNG-IUS inserted at 45 years or over, the device can be left for contraceptive purposes until the menopause.

Answer 31

• Heavy menstrual bleeding • Endometriosis • Adenomyosis • Dysmenorrhoea • Endometrial protection • Simple hyperplasia

Answer 32

Contraindications: 1-pregnancy. 2-multiple fibroids. 3-congenital uterine abnormality. 4-acute or sub acute PID or active vaginal inflammation. 5-ca. of the cervix or of body of uterus. 6-valvular heart disease (risk of bacterial endocarditic). 7-abnormal uterine bleeding. 8-known allergy to copper if a copper IUCD is being chooses.

Answer 33

Insertion: An IUD can be fitted at any point in the cycle provided there is no risk of pregnancy. Postpartum insertion; should be delayed 8 weeks to decrease the risk of expulsion & perforation especially in lactating woman. IUD can be inserted immediately after abortions; although expulsion rates may be higher in second trimester abortion. Efficacy; during first year after insertion between 2-3% of women will conceive. Levonorgestril is more effective 0.1. Side effects: 1-Menstrual disturbances: the effects of IUD on the endometrial particularly. The local PGs tens to cause increase menstrual bleeding & dysmenorrheal. Also IUD may cause irregular bleeding. In contrast the levonorgestril IUD decrease the blood loss. 2-Perforation; usually occur at the time of insertion;& it is often unnoticed . It is about 1:1000 & most frequently is through the uterine fundus. It should be suspected when at the routine follow up (6 weeks later) there e is absence of the thread (other 2 possibilities is either expulsion of the device or it is rotated within uterine cavity). Pelvic u/s or x-ray will help to localize the device. Intraperitoneal devices can be recovered through laparoscope or sometime laprotomy. 3-expulsion; rate vary from 1-20 women, most commonly in the first 3 months of use. • 4-ectopic pregnancy; women using IUD has 80% decrease in the risk of ectopic pregnancy compared with women not using contraception.but if pregnancy occur with IUCD more likely it is ectopic pregnancy. • The ectopic pregnancy rate for Cu-IUD users is 0.02 per 100 WY (0.3–0.5 per 100 WY for those not using contraception) 5-pelvic infection; infection is most likely to occur during the 20 days following insertion Actinomycosis occur more with IUCD. -pregnancy with IUCD in place; increase risk of about 3 x & removal of IUCD will decrease the risk of abortion. If the IUCD left in place there is slight risk of intrauterine infection, preterm labour,second trimester miscarriage &APH, but most pregnancies are uncomplicated & the device is delivered with the placenta.

Answer 34

Formulations:- It contains both estrogen(usually Ethinyl oestradiol or Menstranol) & a progesterone. Previously use high dose pills (100 ug of estrogen), but now decrease the dose of estrogen to 20-50 ug; most women use 30-35 ug estrogen (low- dose pills). The progesterone either 1 st or 2 nd or 3 rd generation  The pill is taken for 21 days followed by a 7-day break during which time withdrawal bleeding usually occurs. The pill should be taken at the same time each day, bed time is convenient. If the woman forgets to take the pill one night she can take it the next morning.  Combined pills are available as monophonic (preparation in which every pill in the pocket contains the same dose of steroids); & biphasic & triphasic pills ; in which the dose of both steroids changes once or twice during the cycle so that the regimen will mimics the normal cycle. Mode of action:-  The principle mode of action of COC is the inhibition of ovulation. Estrogen inhibits FSH (suppressing the development of ovarian follicles, while progestogens inhibit the development of LH surge.  Additional contraceptive effects include changes in the cervical mucus characteristics interfering with sperm transport, a possible alteration in the tubal motility, endometrial atrophy with impaired uterine receptivity. Advantages:- 1. Menstrual periods are usually lighter, shorter & more regular during the pill use, less painful & premenstrual symptoms less troublesome. 2. Decrease the incidence of iron deficiency anemia by decreasing menstrual blood loss. 3. Decrease incidence of benign breast lumps, functional ovarian cysts, endometriosis, acne & possibly PID. 4. COC use protects against ovarian & endometrial cancer (due to decrease in the number of ovulations & therefore rupture of ovarian capsule).  There is also a 50 per cent reduction in ovarian and endometrial cancers which continues for 15 years after stopping the CHC.  5.There is a possible protective effect against rheumatoid arthritis, thyroid disease and duodenal ulceration.

Answer 35

Advantages:- 1. Menstrual periods are usually lighter, shorter & more regular during the pill use, less painful & premenstrual symptoms less troublesome. 2. Decrease the incidence of iron deficiency anemia by decreasing menstrual blood loss. 3. Decrease incidence of benign breast lumps, functional ovarian cysts, endometriosis, acne & possibly PID. 4. COC use protects against ovarian & endometrial cancer (due to decrease in the number of ovulations & therefore rupture of ovarian capsule).  There is also a 50 per cent reduction in ovarian and endometrial cancers which continues for 15 years after stopping the CHC.  5.There is a possible protective effect against rheumatoid arthritis, thyroid disease and duodenal ulceration. WHO medical eligibility criteria category 4 for combined hormonal contraception of OCCP (absolute) * raindication  CHC: UKMEC Category 4 – Unacceptable health risk and should : not be used Non-lactating ->Jweeks lactating ji  Breastfeeding – <6 weeks postpartum " & to decrease 6 · women -> , months . risk of DVT because pregnancy itself increase risk of DVT  Smoking – aged ³35 years and smoking ³15 cigarettes per day  Cardiovascular disease – multiple risk factors for arterial cardiovascular . disease  Hypertension – blood pressure ³160 mmHg systolic and/or ³95 mmHg diastolic; or vascular disease  VTE – current (on anticoagulants) or past history  Major surgery with prolonged immobilisation  Known thrombogenic mutations  Current and history of ischaemic heart disease  Stroke  Valvular and congenital heart disease – complicated by pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis  Migraine headaches – with aura at any age  Breast disease – current breast cancer  Diabetes – with nephropathy, retinopathy, neuropathy or other vascular disease  Viral hepatitis – active or flare  Cirrhosis – severe decompensated disease  Liver tumours – benign hepatocellular adenoma and malignant hepatoma  Systemic lupus erythematosus (SLE) – positive or unknown antiphospholipid antibodies Risks & side effects:- A-Minor S/E :1.Disturbances of the menstrual cycle: either slight bleeding or frank break through bleeding especially with low dose pills. If frank through bleeding ˃ 2 times the can be controlled by increasing the dose of estrogen or change to another preparation contains different proportion of estrogen to progesterone. Amenorrhea when high –dose pills. Exclude pregnancy & sometimes can be treated by induction of ovulation. 2.Weight gain, fluid retention, headache, nausea, & vomiting, chloasma, mood changes, loss of libido, mastalgia, breast enlargement & greasy skin. B-Serious S/E :  1.CVS: on venous side; increase risk of venous thrombosis & pulmonary embolism. In dosedependent pattern related to the amount of estrogen in the pill. Estrogen increase platelet count & platelet adhesiveness & decrease ant thrombin in blood.  This risk is the most during the first year of CHC use. On arterial side: including hypertension, CVA,& coronary heart disease. Increase risk was only seen on smoker woman on the pill. 2.Carbohydrate metabolism: high dose pills will decrease carbohydrate tolerance. 3.Malignancy: small increase in breast cancer & that the risk persisted for 10 years after stopping the pills especially if she take the pills before the birth of the first child. Also small increase in the risk of carcinoma of cervix. Liver cancer; benign hepatic adenoma is rare complication. Interaction with drugs:  Effectiveness of the combined oral contraceptive pill (COCP) (and all other methods) is not affected by administration of most broad-spectrum antibiotics.  Barbiturates, sulphonamide, rifampicin, phenytoin & most anticonvulsants will increase activity of liver enzymes that metabolize the steroids.  Effect on pregnancy: no increase in the incidence of congenital abnormality in woman who has taken the pills after pregnancy has started.  Follow up: B.P checked at 6, 12 months, then annually, Pap smear annually .examine breast each year.

Answer 36

 If ONE pill has been missed (more than 24 hours and up to 48 hours late) .  Continuing contraceptive cover  • The missed pill should be taken as soon as it is remembered • The remaining pills should be continued at the usual time.  Minimizing the risk of pregnancy  Emergency contraception (EC) is not usually required. If TWO OR MORE pills have been missed (more than 48 hours late  Continuing contraceptive cover •  The most recent missed pill should be taken as soon as possible •  The remaining pills should be continued at the usual time •  Condoms should be used or sex avoided until seven consecutive active pills have been taken.  Minimising the risk of pregnancy  If pills are missed in the first week (Pills 1 - 7) .  EC should be considered if unprotected sex occurred in the pill-free interval or in the first week of pill-taking  If pills are missed in the second week (Pills 8 - 14)  No indication for EC if the pills in the preceding 7 days have been taken consistently and correctly (assuming the pills thereafter are taken correctly and additional contraceptive precautions are used).  .  If pills are missed in the third week (Pills 15 - 21)  OMIT THE PILL-FREE INTERVAL by finishing the pills in the current pack (or discarding any placebo tablets) and starting a new pack the next day.

Answer 37

   With this patch 20 μg of ethinyl estradiol and 150 μg of norelgestromin are released every 24 hours. It is the first transdermal contraceptive applied once weekly for 3 weeks followed by a patch-free week (3 weeks on, 1 week off). The Pearl index is 1.24 per 100 WY NuvaRing     releases 120 μg of etonogestrel (ENG) and 15 μg of ethinyl estradiol daily. It is 54 mm in diameter and 4 mm thick. It is placed vaginally once every 3 weeks and following a 1week ring-free interval a new ring is inserted. Efficacy and cycle control are comparable to the COCs. Side-effect profile is also similar to that of COCs. However, women have reported more vaginal symptoms of vaginitis, leukorrhoea, foreign body sensation, coital problems and expulsion.

Answer 38

Available as oral pills, implants, long acting injectables, & recently hormone – releasing IUCD. Mechanism of action: Given in high doses e.g. injectables, progestogens inhibit ovulation. In low doses; ovulation may be inhibited often inconsistently. By all routes progestogens affect cervical mucus reducing sperm penetrability & transport & all have an effect on the endometrium which probably compromises implantation. S/E: All low dose progesterone – only methods are associated with high incidence of irregular bleeding because ovulation inhibited inconsistently .Also progestogens may alter the vasculature of the endomrtium increase the chance of bleeding. Efficacy:   POP has a higher failure rate than COC. Failure rates for traditional POPs vary from 0.3 to 8.0 per 100 WY. The decrease efficacy is due in part that many women continue to ovulate & in part because the POP has a shorter half- life in the circulation. Indications of POP: 1.In women in whom estrogen is absolutely or relatively contraindicated as women with CVS risk factors, migraine, D.M or mild hypertension. 2. Lactating women since estrogen impairs milk production.  POP: UKMEC Category 3 – Risks generally outweigh benefits  Current and history of ischaemic heart disease and stroke – continuation of the method  Past history of breast cancer and no evidence of recurrence for 5 years  HIV – on antiretroviral therapy (drug interactions)  Cirrhosis – severe (decompensated)  Liver tumours – hepatocellular adenoma and malignant hepatoma  SLE – positive or unknown antiphospholipid antibodies  POP: UKMEC Category 4 – Unacceptable health risk and should not be used  Breast disease – current breast cancer S/E: 1.Irregular vaginal bleeding. 2.High incidence of functional ovarian cysts due to effect on ovarian activity. 3.Headache, nausea, bloating, breast tenderness & mood changes, oily skin & acne. 4.Long –term risks: very small increase in the risk of carcinoma breast after prolonged use of POP (Depo- Provera confers a high degree of protection against endometrial ca.).

Answer 39

   TRADITIONAL POPS (Micronor*, Noriday*, Norgeston*, Femulen >3 hours late (>27 hours since the last pill was taken) Take a pill as soon as remembered. If more than one pill has been missed just take one pill. Take the next pill at the usual time. This may mean taking two pills in one day. This is not harmful. An additional method of contraception (condoms or abstinence) is advised for the next 2 days (48 hours after the POP has been taken).

Answer 40

 >12 hours late  (>38 hours since the last pill was taken)  Take a pill as soon as remembered. If more than one pill has been missed just take one pill. Take the next pill at the usual time. This may mean taking two pills in one day. This is not harmful. An additional method of contraception (condoms or abstinence) is advised for the next 2 days (48 hours after the POP has been taken).

Answer 41

3types: 1. Depo-Provera (medroxy-proesterone acetate given in a dose of 150 mg every 12 weeks. 2.Norethisterone –enanthate 200 mg given every 8 weeks. Subcutaneous DMPA (Sayana Press) 104 mg given subcutaneously every 13 weeks. It can be injected into the upper anterior thigh or anterior abdomen . S/E: 1.Irregular vaginal bleeding (treated by administration of estrogen simply by adding the combined pills). 2.Amenorrhea. 3.Delayed fertility; it may take 1 year for normal fertility to return following cessation of depo provera.  4.Decrease bone marrow density (BMD); Amenorrhea →hypooestrog. →↓BMD.  5.Weight gain  The average weight gain among women using DMPA is between 2 and 6 kg.

Answer 42

Nexplanon  is the only POI available in the UK. It has replaced Implanon.  It is a single rod which contains 68 mg of etonorgestril ENG in a membrane of ethylene vinyl acetate. It is licensed for 3 years.  Nexplanon is radio-opaque  . Nexplanon® is a flexible rod (40 mm × 2 mm) and is inserted  subdermally 8 cm above the medical epicondyle, usually of the non-dominant arm.  Insertion  is conducted under local anaesthesia using a specially designed insertion device. Mode of action    The main mode of action is inhibition of ovulation . Thickening of the cervical mucus prevents sperm penetration into the upper reproductive tract. It also brings about changes in the endometrium making the environment unfavourable for implantation . Side effects  irregular bleeding and oligomenorrhoea/ amenorrhoea.  Weight gain .  Mood changes and loss of libido can occur.  Acne can improve, occur or worsen whilst using the implant.  Complications with removal  include deeply sited, non-palpable, broken or migrated implants. As Nexplanon contains barium sulphate it is radio-opaque. Hence it can be identified on X-rays. Ultrasound and MRI can also be used to locate the implants.

Answer 43

Is any drug or device used after intercourse to prevent pregnancy, to prevent implantation of a fertilized egg. 1Yuzpe regimen. 2 tablets of high –dose estrogen (100ug) & 500ug levonorgestrel repeated after 12 hours. S/E nausea & vomiting. The dose should be given within 72 hours of coitus.  2.Levonorgestrel 1.5 mg once up to 3 days. Replace yuzpe regimen.  it works mainly by inhibiting ovulation. It prevents follicular rupture.  It can be used more than once in a cycle.  3.IUCD is highly effective postcoital contraception with failure rate < 1%. It is used up to 5 days after coitus.or 5 days after ovulation  should be the first-line choice, particularly if the woman intends to continue the IUD as long-term contraception .  When used for EC, its effect on the endometrium is thought to prevent implantation if fertilization has occurred            4. ellaone-ulipristal acetate 30mg single dose tablet If vomiting occurs within 3 hours, another tablet should be taken. Ulipristal is not recommended to be used more than once per cycle as the safety of efficacy of repeated exposure has not been assessed . Is progesterone receptor modulator . Its primary mode of action is thought to be inhibition or delay of ovulation. It can prevent ovulation after the LH surge has started. Effective up to 120 hours after coitus. Levo norgestrel effective 69% Ulipristal 85%. Oral EC is much less effective than the Cu-IUD for EC and is estimated to prevent only two-thirds of pregnancies. • Effective ongoing contraception should be started after EC.

Answer 44

 Sterilisation is a permanent and usually an irreversible method of contraception . 1-Female sterilization  It involves blocking both fallopian tubes by laprotomy, mini-laprotomy, & more commonly by laparoscope or via hysteroscopy. Bilateral salpingectomy or hysterectomy may be preferable when there is coexistent gynecological pathology. Methods of tubal occlusion:  1.Ligation (using absorbable or non- absorbable sutures)  The Pomeroy technique is the most widely used ligation technique . 2.Electrocautery. 3.Rings. 4.Clips. 5.Laser (co2 laser).  6.Chemical agents instilled into fallopian tubes e.g. quinacrine.  The failure rate for female sterilisation is 1 in 200. Hysteroscopic sterilisation  Micro-inserts made from nickel–titanium and stainless steel are inserted hysteroscopically through the cornual ends of both tubes.  This can be performed under local anaesthesia and/or intravenous sedation. These generate fibrosis around the devices and the tubes are occluded by 3 months after the procedure.  Additional contraception needs to be used until a hysterosalpingogram is performed at 3 months to confirm full occlusion of the tubes.  It is an irreversible procedure and the failure rates quoted are the same as for the other methods of tubal occlusion. Complications: A-Immediate complications 1. Complication of G.A. 2. Vascular damage or damage to bowel or other internal organs especially with electrocautery. 3. Gas embolism. 4. Thrombo-embolism.  5. Wound infection. B- Long –term complications  1.Menstrual disorders. There is no evidence to suggest that there is an increased incidence of bleeding problems and consequently an increased hysterectomy rate after tubal occlusion. 2.Abdominal pain & dysparunia (more common after cautery). 3.Psychological problems & psycho-sexual problems. 4.Bowel obstruction from adhesions (very rare). Vasectomy (male sterilization) Division or occlusion of the vas deferens prevents the passage of sperm using clips or diathermy or injection of sclerosing agents as silicone.   Efficacy: failure rate is 1 in 2000. The procedure can be carried out under a local anaesthetic and is safer than female sterilisation. Following the procedure, men should be advised to use effective contraception until two consecutive semen samples 4 weeks apart confirm azoospermia. (The first sample should be taken at least 8 weeks after surgery.) Complications A-Immediate 1. Scrotal hematoma, wound infection. 2. Up to 2 % men fail to have azospermia in which case vasectomy repeated.

Answer 45

The definitive diagnosis of a molar pregnancy is made by histological examination. Ploidy status and immunohistochemistry staining for p57, a paternally imprinted gene, may help in distinguishing partial from complete molar pregnancies. Removal of a molar pregnancy Complete molar pregnancies are not associated with fetal parts, and therefore, suction removal is the method of choice for uterine removal irrespective of uterine size. Medical removal of a complete molar pregnancy should be avoided if possible, irrespective of the agents used. Ultrasound guidance during removal and curettage may be of use to minimize the chance of perforation and to ensure that as much tissue as possible is removed. Suction curettage is the method of choice for removal of partial molar pregnancies except when the size of fetal parts deters the use of suction curettage and then medical removal can be used. Anti-D prophylaxis is recommended following removal of a molar pregnancy. Excessive vaginal bleeding can be associated with surgical management of molar pregnancy. There is theoretical concern over the routine use of oxytocic agents, including ergometrine and misoprostol,because of the potential to embolism and disseminate trophoblastic tissue through the venous system. In the event of life-threatening haemorrhage or ongoing bleeding, oxytocic infusions may be used. Theca-lutein ovarian cysts tend not to be symptomatic and typically regress after molar evacuation. In extreme cases, these may be aspirated if symptomatic, but oophorectomy is not performed except when torsion leads to extensive ovarian infarction

Answer 46

In what circumstances should a repeat surgical removal be indicated and what is the timing? Women with persistent heavy vaginal bleeding and evidence of retained pregnancy tissue on ultrasound examination may need a repeat surgical removal and hCG is less than 5000 units/l. Expediting surgical management in the case of acute haemodynamic compromise is the priority and delay can be harmful. How should suspected ectopic molar pregnancy in women be managed? women with ectopic pregnancy suspected to be molar in nature should be managed as any other case of ectopic pregnancy. If there is a local tissue diagnosis of ectopic molar pregnancy, the tissue should be sent to a center with appropriate expertise for pathological review. Twin pregnancy of a viable fetus and presumptive coexistent molar pregnancy Women diagnosed with a combined molar pregnancy and viable twin, or where there is diagnostic doubt, should be referred to a regional fetal medicine center and GTD center. 9 * if the diagnosis is clear : In the situation of a twin pregnancy where there is one viable fetus and the other pregnancy is molar, the woman should be counselled about the potential increased risk of perinatal morbidity and the ↳ outcome for GTN. pre-eclamsia bleeding metastases Uterine rupture , , , - * if the diagnosis not clear: Prenatal invasive testing for fetal karyotype should be considered in cases where it is unclear if the pregnancy is a complete mole with a coexisting normal twin or a possible singleton partial molar pregnancy. Prenatal invasive testing for fetal karyotype should also be considered in cases of abnormal placenta, such as suspected mesenchymal hyperplasia of the placenta

Answer 47

follow-up following a diagnosis of GTD GTN develop after evacuation in 15 percent of patient with complete moles, and only in4 to6 percent of partial mole * female presented after 3 weeks of delivery as vaginal bleeding No pathologic or initial clinical feature accurately predict which patient will ultimately develop GTN ,so serial B-hCG level fallowing molare evacuation can used to effectively monitor patient with GTN development Titer are monitored fallowing uterine evacuation at least every 1to 2week until they become undetectable For complete molar pregnancy, if hCG has reverted to normal within 56 days of the pregnancy event then follow-up will be for 6 months from the date of uterine removal. If hCG has not reverted to normal within 56 days of the pregnancy event then follow-up will be for 6 months from normalization of the hCG level. Follow-up for partial molar pregnancy is concluded once the hCG has returned to normal on two samples, at least 4 weeks apart. Women who have not received chemotherapy no longer need to have hCG measured after any subsequent pregnancy event. PROFELACTIC CHEMOTHERAPY Chemotherapy can be administered to help prevent GTN development in high risk patient who are:  unlikely to compliant  whom B-hCG surveillance is not available  age>40  history of molar pregnancy with an excessively high titer prior to evacuation

Answer 48

GTN is diagnosed & & based on elevated ~-hCG level and managed clinically.

Answer 49

Gestational Choriocarcinoma This extremely malignant tumor contains sheets of anaplastic trophoblast and prominent hemorrhage, necrosis, and vascular invasion. However, formed villous structures are characteristically absent .Gestational choriocarcinoma initially invades the endometrium and myometrium but tends to develop early blood-borne systemic metastases. Most cases develop fallowing evacuation of a molar pregnancy, but this tumor may also fallow a non-molar pregnancy. the diagnosis of choriocarcinoma is delayed fure months due to subtle signs and symptoms. Most patients present with. intermenstrual bleeding, and high B-hCG levels are detected Thus, abnormal bleeding for more than 8weeks following any pregnancy warrants evaluation With B-hCG testing to exclude a new pregnancy or GTN. Less Frequently, the diagnosis is made in an asymptomatic woman by an incidental positive pregnancy test In part because of the typical delay to diagnosis, choriocarcinomas following term pregnancies are associated with high-risk features and a higher mortality rate than GTN following non-molar abortions. Placental-Site Trophoblastic Tumor This tumor consists predominantly of intermediate trophoblasts at the placental site. It is a rare GTN variant with unique disease behavior. Placental-site trophoblastic tumor (PSTT) can follow any type of pregnancy but develops most commonly following a term gestation. Typically, patients have irregular bleeding months or years after the antecedent pregnancy, and the diagnosis is not entertained until endometrial sampling has been performed. PSTT tends to infiltrate only within the uterus, disseminates late in its course, and produces low B-hCG levels Of interest, an elevated proportion of free B-subunit can help to discriminate it from other GTN types if the endometrial biopsy is equivocal . For those with stage I disease but high-risk tumor features, chemotherapy can be considered. When this tumor does spread, the pattern mirrors that of gestational choriocarcinoma. Metastases often spread to the lungs, liver, Hysterectomy is the primary treatment for non-metastatic PSTT due to its relative insensitivity to chemotherapy. In particularly motivated patients, fertilitysparing procedures have mixed results Metastatic PSTT has a much poorer prognosis than its pos-tmolar GTN counterparts. As a result, aggressive combination chemotherapy is indicated. Regimens of etoposide, methotrexate, and dactinomycin (actinomycin D) that alternate with etoposide and cisplatin (EMA/EP) are considered the most effective . Epithelioid Trophoblastic Tumor This rare trophoblastic tumor is distinct from gestational choriocarcinoma and PSTT. The preceding pregnancy event may be remote, or in some cases, a prior gestation cannot be confirmed Epithelioid trophoblastic tumor (ETI) develops from neoplastic transformation of chorionic-type intermediate trophoblast. Microscopically, this tumor resembles PSTT, but the cells are smaller and display less nuclear pleomorphism. Grossly, epithelioid trophoblastic tumor grows in a nodular fashion rather than the infiltrative pattern of PSTT. Hysterectomy is again the primary treatment due to presumed chemoresistance and because the diagnosis is usuallyconfirmed in advance by endometrial biopsy. Chemotherapy options mirror that for PSTT. More than one third of patients will present with metastatic disease and demonstrable chemoresistance to multiagent therapy.

Answer 50

1. Rising hCG in two or plateaued in three consecutive serum samples 2. Raised hCG level 6 months after evacuation (even if falling) 3. Histological evidence of choriocarcinoma 4. Metastases to the brain, liver, gastrointestinal tract, spleen, kidneys or other solid organs 5. hCG >20 000 IU/L more than 4 weeks after evacuation 6. Heavy vaginal bleeding or gastrointestinal/intraperitoneal bleeding 7. Lung or vaginal metastases >2 cm

Answer 51

Assessment Patients with GTN undergo a thorough pretreatment assessment to determine disease extent. The initial evaluation may be limited to pelvic examination, chest radiograph, and pelvic sonography or abdominopelvic computed tomography (CT) scanning. Laboratory tests include CBC,B-hCG levels, and measure of liver, renal, and thyroid function. Although approximately 40 percent of patients will have micrometastases not otherwise visible on chest radiography. chest CT is not needed because these small lesions do not affect outcome However, pulmonary lesions identified on chest radiograph should prompt CT of the chest and magnetic resonance (MR) imaging of the brain. Fortunately, central nervous system involvement is rare in the absence of neurologic symptoms or signs .Positron emission tomography (PET) may occasionally be useful to evaluate occult choriocarcinoma or relapse from previously treated GTN when conventional imaging is equivocal or fails to identify suspected Metastatic disease .

Answer 52

Stage I Disease confined to the uterus Stage II GTN extends outside of the uterus but is limited to the genital structures (adnexa, vagina, broad ligament) Stage Ill GTN extends to the lungs, with or without known genital tract involvement Stage IV All other metastatic sites FIGO = International Federation of Gynecology and Obstetrics; GTN = gestational trophoblastic neoplasia. Patients at low risk for therapeutic failure are distinguished from those at high risk by wing the modified prognostic scoring system of the World Health Organization (WHO) score of 0 to 6 and will be considered to have low-risk disease The remainder will have a score of7 or higher and be assigned to the high-risk GTN group

Answer 53

the current recommendation is that a repeated evacuation should only be considered if the hCG level is under 5000 IU/L and tissue is seen in the uterine cavity on ultrasound.For patients meeting the FIGO standard for low-risk treatment, the most widely used protocol is methotrexate given intramuscularly with oral folinic acid rescue following the schedule The low-risk methotrexate and folinic acid chemotherapy treatment schedule. The first course of treatment should be administered in hospital with the subsequent courses administered at home. This is because they have a higher risk of bleeding as therapy starts, particularly if the tumor shrinks rapidly with the initial chemotherapy. Bleeding usually responds well to strict bed rest and less than 1% of low-risk patients require emergency interventions such as embolization, vaginal packing or hysterectomy For low-risk patients with lung metastases visible on their chest radiographs perform MRI of the head and if normal to add CNS prophylaxis with intrathecal methotrexate administration to minimize the risk of development of CNS disease. A maximum of follow three doses of intrathecal methotrexate is given unless the upmy cerebrospinal fluid to serum hCG ratio exceeds 1 : 60 ~ * followed by B-hCG => every 1-2 weeks Treatment is continued until normalization of the serum hCG level (0–4 IU/L) and then a further three cycles (6 weeks) to ensure eradication of any residual disease that is below the level of serological detection

Answer 54

High-risk disease management one-third of high-risk patients EMA/CO chemotherapy . is myelosuppressive and most patients require granulocyte colony-stimulatingfactor support each week to maintain treatment intensity and to minimize the risk of neutropenic sepsis. Nausea and vomiting are now rarely a problem with antiemetics that include the 5HT3 receptor antagonists such as ondansetron combined with domperidone. some patients develop peripheral neuropathy that can be aided by stopping the vincristine Ultra-high-risk disease Ultra-high-risk disease is a new term to try to define those high-risk patients at greatest risk of death. the causes of death in patients with high-risk disease either early or late. The early deaths took place within 4 weeks of admission due to organ failure associated with one or more of the following: fatal haemorrhage, metabolic upset from tumour lysis and very adavanced disease. The late deaths were from multiresistant disease. In addition, some deaths were due to cancers that were in fact non-gestational epithelial malignancies histopathologically mimicking gestational choriocarcinomas. Factors associated with early or late deaths included: a FIGO score above 12, very advanced lung disease, liver with or without brain metastases, and an interval from the last-known and presumed causative pregnancy greater than 2.8 years. chemotherapy comprising low-dose etoposide 100 mg/m2 and cisplatin 20 mg/m2 (EP) given intravenously on days 1 and 2 and repeated weekly for up to 3weeks until the patient is well enough to tolerate standard-dose therapy. For patients with brain metastases, the methotrexate dose is increased to 1 g/m2 in the EMA and intrathecal methotrexate is given with the EP to ensure adequate CNS penetration. We also extend the duration of consolidation therapy in ultra-high-risk patients to 8 weeks.

Answer 55

Surgery Hysterectomy 1. Hysterectomy may be performed to primarily treat PSTI, ETI, or other chemotherapy-resistant disease. 2. Uncontrollable vaginal or intraabdominal bleeding may necessitate hysterectomy 3. adjuvant hysterectomy decreases the total dose of chemotherapy needed to achieve clinical remission in low risk GTN. 4. Patients with disease apparently confined to the uterus who do not desire future fertility should be counseled about this option thoracotomy will have stage III GTN, a preoperative B-hCG level < 1500 mIU I mL, and a solitary lung nodule resistant to chemotherapy

Answer 56

Any woman who develops persistent vaginal bleeding after a pregnancy event is at risk of having GTN. D A urine hCG test should be performed in all cases of persistent or irregular vaginal bleeding lasting more than 8 weeks after a pregnancy event. Symptoms from metastatic disease, such as dyspnea and hemoptysis, or new onset of seizures or paralysis, can occur very rarely. Biopsy of secondary deposits in the vagina can cause major haemorrhage and is not recommended.

Answer 57

Subsequent fertility fertility is not clearly affected by single agent therapy with methotrexate and apart from hastening the menapause by 3 years. EMA/CO appears to also have no impact on the chances of a successful pregnancy, which for both methotrexate alone or EMA/CO is 83%. Further pregnancy should be deferred for 12 months after treatment to avoid any teratogenic effects on developing oocytes and to minimize possible confusion from the rising hCG levels between a new pregnancy and disease relapse. CONTRACEPTION COC use decreases the likelihood of pregnancy compared with less effective barrier contraception and does not increase the risk of GTN . Injectable medroxyprogesterone acetate is particularly useful when poor compliance is anticipated. In contrast, intrauterine devices are not inserted until the B-hCG level is undetectable because of the risk of uterine perforation if an invasive mole is present.

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