Gyne Flashcards
(142 cards)
1
Q
What are the indications to admit a patient with a diagnosis of PID (7)?
A
Severe illness
Tubo-ovarian abscess
Cannot r/o other surgical emergency
Unable to take oral meds
Not responding to PO meds
Pregnancy
Non-reliable
2
Q
What are the predictors of endometrial ablation failure (3)
A
Age < 40
Prior tubal ligation
Preoperative dysmenorrhea
3
Q
What is the average age at diagosis of LMS
A
52
4
Q
What is the change of concomittent endometrial cancer when hyperplasia with atypia is present
A
17 - 25 %
5
Q
What causes endometrial implants to be so hyper-estrogenic?
A
Implants express:
- Aromatase
- 17 beta hydroxysteroid dehydrogenase type 1
- All genes required in the stereogenesis cascade to make estradiol from cholesterol
Implants lack
- 17 beta hydroxysteroid dehydrogenase type 2 (inactivates estrogens)
6
Q
What is the most common adverse event following non- resectoscopic EA?
A
Pelvic pain
Cramping
Nausea/ vomiting
Resolve within 24h
7
Q
What is the DDx of a black vulvar lesion?
A
Lentigo
Nevus
Vitiligo
Cherry Hemangioma
Melanosis
Sebrroric keratosis
Melanoma
VIN / Vulvar cancer
BCC
8
Q
Should you give abx for cardiac patients to prevent endocarditis?
A
Not for GU procedures
If high risk pts and receiving abx for something else, should consider using Abx that will also cover enterococci
9
Q
What is the % of patient requiring a hysterectomy within 10 years of a myomectomy
A
10 %
10
Q
What is the risk of PPH in patient with vWD/ Facto XI/ hemophilia carriers
A
16 - 22 %
Normal population 4-5 %
11
Q
What are potential test that may aid in LMS pre-op dx
A
MRI
Serum LDH
Endometrial biopsy
12
Q
Name the side effects of progesterone (4)?
A
Acne
GI Upset
Edema
Weight gain
Irregular menstrual bleeding
13
Q
What is the risk of occult sarcoma at time of fibroid surgery
A
1/350 - 1/2000
14
Q
What ovary torts more frequently?
(#341)
A
Right ovary
(sigmoid?)
15
Q
What is the incidence of vault prolapse post hysterectomy in patient with no evidence of POP
A
1-2 %
16
Q
What is the most common cause of secondary dysmenorrhea?
Name other causes of secondary dysmenorrha (5)
A
The most common cause: Endometrioisis
Other causes:
Adenomyosis
Uterine myomas
Cervical stenosis
Obstructive lesions of the genital tract
17
Q
Define primary dysmenorrhea (#345)
A
Menstrual pain in the absence of pelvic pathology
18
Q
What is the inheritence pattern of vWD
A
19
Q
About GnRH agonists for AUB,
1- What is the expected % schrinkage of fibroids
2- When is the greatest effect apparent
A
50 % decrease in initial volume
Greatest effect after 12 weeks
20
Q
What progesterone and what dose is released daily with a Mirena ?
A
Levonorgestrel
20 ug/ day
21
Q
What is the angle of knee abduction recommended in gyne surgery ?
A
< 90 degrees
22
Q
What is the typical apparence of endometriotic lesions in adolescents?
A
Clear vesicles
Red lesions
vs: classic powder burn lesions
23
Q
At what weight should you adjust pr-op abx?
A
120 kg
Previously BMI > 35
24
Q
At what deficit should you abort a ablative procedure ?
For both types of media
A
Non conductive solutions : 1500 mL
(Glycine, mannitor, sorbitol, cystosol)
Conductive solutions: 2500 mL
(NS)
25
What is the mechanism of action of Desmopressin (DDAVP) for vWD
Releases vWF from storage sites within endothelial cells
--\> increases vWF
--\> increase plasma levels of factor 8
26
What are the alternative regiment for Abx prophylaxis in gyne surgery?
Clinda 600 mg IV
Erythro 500 mg IV
Flagyl 500 mg IV (?) - Dose not specified
27
What are the options to treat breakthrough bleeding (in patients w vWD)?
Double COC pill for 3-4 days
Add a 50 ug estrogen patch for 3-4 days
Change to a 50 ug pill
28
What are the anti-androgenic progestins
Norethedrone (NETA)
Drosperinone
Desogestrol
29
What are the types of vWD
Type 1 : partial quantitative reduction in VWF
Type 2: qualitative deficiency of VWF
Type 3: absence of VWF
30
31
What are the **absolute contraindications** to endometrial ablation (5)?
Pregnancy
Desire to preserve fertility
Endometrial cancer or hyperplasia
Cervical cancer
Pelvic infection
32
What is the most common cause of secondary dysmenorrhea in adolescents?
Endometriosis
33
What are the mechanism of fluid overload in hysteroscopy (3)?
**Absorption** across the **endometrium**
**Intravasation** through **surgically opened venous channels**
**Spill** from fallopian tubes with **absorption by peritoneum**
34
Name the RF for LMS (7)
(# 371)
Age \> 50
Black race
Tamoxifen use
Previous pelvic radiation
Hereditary leiomyomatosis
Hx of hereditary retinoblastoma
Renal cell carcinoma
35
Are Abx recommended for HSG?
Only if tubes are dilated (doxy)
36
Are GnRH agonists linked to decreased bone mineral density
Yes (especially if used long term)
37
Is ablative or excisional treatment better for pain management in endometriosis?
No difference for pain (or fertility treatment)
38
List the 4 criteria for endometriosis and epithelial ovarian cancer
Presence of both **endometriosis** and **malignancy** **within the same ovary**
**Carcinoma** must **arise** from the **endometriosis** and not invade from another source
Specimen must contain **histological characteristics** of endometriosis i**ncluding stroma and glands**
There must be **morphological continuation** between **benign** and **malignant epithelium** within the endometriosis
39
What is the treatment of choice for severe vWD?
How long does it last?
**Humate P**
Viral inactivated, pooled human plasma concentrate containing factor 8 and vWF
Replaces vWF for 12 - 24 h
(FFP and Cryo only when Humate P is not available)
40
Does hysterectomy alone affect ovarian reserve?
YES
2-fold increased risk of ovarian failure
\> 20 % pts have symptoms of decreased ovarian reserve within 1y
Decrease AMH shown in studies
41
What are the risk factors for fluid overload (4)?
Use of hypotonic solutions (vs isotonic)
Long procedures
High distension pressure
Resection of large pieces of tissue
42
What are the options for treatment of acute hemorrhage post endometrial ablation (3)
AFTER r/o Uterine perforation:
Foley ballloon tamponade
Intracervical vasopressors injections
Misoprostol PR
43
What are potential complications of pregnancy following endometrial ablation (3)?
Uterine rupture
Limb defects
Premature labour
44
What is the rate of fibroid recurrence after myomectomy
15 %
45
Which treatment for endometriosis causes bone loss?
GnRH agonists
Depot-progestins
46
What is the preferred regimen of Abx for a therapeutic abortion?
**Doxycycline**
100 mg PO pre-procedure
200 mg PO post-procedure
47
What method of hysterectomy has the lowest post-op morbidity or complication rate
Vaginal
48
Name the investigations required before an endometrial ablation
Pregnancy test
PAP test within 2 years
EMB
Assessment of uterine cavity for Mullerian anomalies or intercavitary pathologies (TVUS, hysteroscopy, contrast sonography)
Cervical cultures PRN
49
What epithelial cancer is linked to endometriosis?
**Clear cell cancer (35%)**
Endometrioid (20%)
50
How do factor 8 (VIII) and vWF evolve in pregnancy ?
They increase in pregnancy
Reach their maximum between 29 - 35 weeks
Return to baseline 7-10 days post delivery
Remove epidural catheter directly PP as factors are the highest
51
After how many weeks can we assess the efficacy of endometrial ablation
6 - 12 weeks post op
52
What is the first line therapy in patient with late PPH and vWD
Cyklokapron + OCP
Can start prophylactic OCP immediatly PP and for 1 month
53
What is the inheritence pattern of Hemophilia A and B
Both X linked
Hemophilia A (Factor 8 deficiency)
Hemophilia B (Factor 9 deficiency)
54
Are antibiotics recommended before endometrial ablation?
No
55
What are the criteria to observe vs operate an endometrioma?
Asymptomatic
Small endometrioma with classic findings
Established diagnosis of endometriosis
Stable Ca125
56
When should you supress ovarian function in women with endometriosis and infertility?
Patient who undergo IVF
(GnRH agonist x 3-6 mo)
**Not effective for**
- mild to moderate disease
- pre-op surgery for endometriosis
57
Which of the 2 medications have a shorter time to ammenorrhea - GnRHa vs Ulipristal
Ulipristal (7 vs 21 days)
58
What is the ideal technique to remove superficial endometriosis for fertility purposes?
No difference in terms of fertility
Excision = ablation
Electrocautery = laser
59
What should be added to GnRH agonist for treatment of endo in adolescents (3)?
Add back therapy
Calcium
Vitamin D
60
What can decrease vWF levels (2)?
Hypothyroidism
Blood type 0 lower than type non-O
61
Describe von Willebrand studies
Factor VIII
vWF antigen
vWF functional assay
62
What are the most common adverse events in resectoscopic ablation (4)?
Uterine perforation
Fluid overload
Hematometra
Cervical lacerations
63
What is the first line treament of menorrhagia in patient with bleeding disorders ?
COCs
64
What is the inheritence pattern of vWD?
Autosomal dominant (Type 1 and some type 2)
Autosomal recessive (some type 2 and type 3)
65
After how long off GnRH agonist treatment are fibroids expected to regrow?
What is the maximum length of continuous tx
12 weeks
3-6 months
66
Name the contraindications to non-resectoscope EA (2)?
Classical CS
Transmural myomectomies
(Caution if \> 2 CS)
67
What are the indications for laparoscopy in endo patients with infertility?
1- Deep dyspareunia, severe dysmenorrhea, dyschezia
2- Tender nodules on uterosacrals
3- Persistent adnexal mass (remove endometrioma if diameter \> 3 cm)
68
What are the advantages of pre-treating the endometrium in resectoscopic EA (3)?
Higher short term amenorrhea
Decreased fluid absorption
Shorter operative times
(Better visualization)
69
What are the 3 indications for surgical management of TOA?
Intra-abdominal TOA rupture
Failure to respond to ABX within 48-72h
Suspicion of other surgical emergencies (ex appy)
70
What can increase vWF levels (8)?
Age
DM
Malignancy
Stress, exercice
Oral contraceptive
Pregnancy
Inflammation (acute or chronic)
Hyper thyroidism
71
Name the effects of decreased estrogen exposure (5)
Hot flushes
Insomnia
reduced libido
vaginal dryness
headaches
72
Name symptoms of intravascular local anesthetic injection
And with epinephrine?
Tinnitus
Blurry vision
Peri-oral / fascial numbness
**With epinephrine:**
Palpitations
Tachycardia
Anxiety
73
What his the angle for hip flexion recommended in gyne surgery?
60 - 170 degrees
74
If a patient has menorrhagia and no local causes were found, vWD investigations are negative, what should you do?
Refer to hematologis to r/o:
Mild factor X1 deficiency
Platelet dysfunction
RARE: alpha 2-antiplasmin, Factor XIII deficiency
75
What is the risk of endometrial cancer with Cowden syndrome
13 - 19 %
76
What is the prevalence of menorrhagia in the general population?
And in patient with bleeding disorders
General population: 10 %
Bleeding disorders: 60 - 90 % (57 - 93 %)
77
What is the inheritance pattern of vWD
Types 1 and most of type 2: Autosomal dominant
Tye 3 and some type 2: Autosomal recessive
78
What is the appropriate discharge teaching for endometrial ablation?
Resume normal activities progressively
No intercourse x 1 week
Pain will resolve within 24h (NSAIDs + opioates)
Light vaginal bleeding x several weeks
Need for permanent contraception
RTC if fever, intense pain or profuse vaginal bleeding
79
What is the risk of endometrial cancer with Lynch syndrome
22 - 50 %
80
81
What is the rate of progression to endometrial cancer in patients with endometrial hyperplasia with atypia treated with progestins
25 % (average time to cancer: 4 years)
82
Through what mechanism of action do COCs improve menorrhagia in vWD patients?
Increasing plasma levels of factor VIII and vWF
83
At what size should an endometrioma be excised?
\> 3 cm
Excision improves pain, recurrence etc but decreases pregnancy rates
Consider drainage/ablation/ surgical management if \< 3cm
84
What is the recommended level of vWF for procedures/ delivery
0.5 U/mL
Keep at that level
- 3-4 days post SVD
- 4-5 days post CS
85
Describe the initial laboratory investigations for menorrhagia (4+3)
Platelet count
Hemoglobin
Prothrombin (PT)
activated partial thromboplastin time (aPTT)
Consider:
TSH
PLR
Liver profile
86
What is the success rate en endometrial ablation?
73-85 % (regardless of technique)
87
In what circumstances would you request von Willebrand studies?
Menorrhagia present since menarche
Evidence of anemia or iron deficiency
Personal or family history of bleeding after hemostatic challenge (dental procedures, surgery, pregnancy)
No local cause of menorrhagia
88
What is the most common inherited bleeding disorder?
What are other bleeding disorders
Most common: von Willebrand disease
Other: Factor XI deficiency, mild platelet disorders
89
How do you follow an endometrioma?
Repeat imaging at 6 -12 wks to r/o hemorrhagic cyst (vs endo)
TVUS yearly
90
At what age can you start GnRH agonist with add back for adolescents?
18 yo -- for everyone (after other tx failed)
16 yo -- if laparoscopically proven endometriosis and not other effective tx
91
Define secondary dysmenorrhea (#345)
Menstrual pain associated with underlying pelvic pathology (ex endometriosis)
92
How can you prevent fluid overload in hysteroscopy (3)
Pre-treat the endometrium
Intracervical injection of pressors (vasopressin/ epinephrine)
Distension pressure \< patient's MAP
93
Indication to repeat Abx prophylaxis (2)?
When should pre-op prophylaxis given?
Sx \> 4h EBL \> 1.5 L
15 - 60 min before incision
94
What is the recommended degree of knee flexion in gyne surgery?
90 - 120 degrees
95
What needs to be present for the histological diagnosis of endometriosis?
(# 164)
Endometrial gland and stroma
96
What is the main mechanism of action of DMPA for chronic pelvic pain?
(#345)
#1 = Suppression of ovulation
#2 = Endometrial atrophy
97
98
Does surgical treatment of endometriosis lesion decrease dysmenorrhea ?
(#345)
Yes !
Ablation or excision
99
Name effective mechanisms (techniques) effective to decrease primary dysmenorrhea (5)?
(#345)
Supression of ovulation
Amenorrhea (by any mean)
Hysterectomy
Laparoscopic nerve ablation (in some cases)
Endometrial ablation (with menorrhagia)
100
Is a pelvic examination / or US required to initiate primary dysmenorrhea treatment?
(#345)
Pelvic exam : no
Indication: not responding to therapy or organic disease suspected
101
What alternative methods can be used for management of primary dysmenorrhea (
(#345)
Regular exercise
Local heat pads
High frequency transcutaneous electrical nerve stimulation
Acupoint stimulation
Ginger
102
Which complications are decreased with laparoscopy vs laparotomies ?
(#193)
Minor complications ↓ by 40 %
Major complications rates are similar
103
Describe Palmer's point
| (#193)
Midclavicular line
3 cm below the left subcostal border
104
How is the umbilicaus of obese women displaced?
(#193)
Caudally to the aortic bifurcation by 2.9 cm
105
What is the advantage of tucking arms in gyne surgery (3)?
(#386)
↓ brachial plexus injury
↓ ulnar nerve injury
Surgeon's comfort
106
What landmark can be used for "umbilical" abdominal entry in obse patients?
(#386)
1/2 way between **pubic symphysis** and **xyphoid** in the **midline**
Can also use palmer's point
- Mid clavicular
- 2-3 cm from costal margin
107
What are the advantages of using Palmer's point for entry in obese patients (5)?
(#386)
**Less fat** compared to umbilicus
**Less adhesions** compared to umbilicus
**Distance to underlying organs increased** (in obese patients)
Prevent entry at umbilicus that migrated caudally (3-6 cm from aortic bifurcation in obese)
Use of **bony structure as landmark** may be more reliable
108
Describe techniques to improve visualization in obese patient laparoscopy without increasing pressure (5)
(# 386)
Foley lap lift
Release peritoneal adhesion of sigmoid
Suspend bowel with epiploic appendices
Suspension of ovaries anteriorly/ laterally
Suspension of bladder via stitch through para-vesical fat
109
Why is OSA a concern for gyne surgery/ anesthesia ?
(#386)
↑ respiratory complications
↑ cardiac events
110
In which population is bariatric surgery recommended ?
(#386)
Class III
Class II with comorbidities
111
Which type of fibroid is more responsive to hormones ?
(#321)
Submucosal fibroids (vs subserosal)
112
How many days pre-op should you stop the following medication:
Warfarin
Dabigatran (Pradaxa)
Rivaraxaban (Xarelto)
Apixaban (Eliquis)
(UpToDate)
**Warfarin : 5 - 6 days**
Measure PT/ INR day before
- INR \< 1.4 → ok for surgery
- INR \> 1.5 → give oral vitamin K (1-2g PO) and recheck next day
**All others: 2-3 days**
113
What are key principles for ventilating ARDS patients?
Low tidal volume
Low inspiratory pressures
High PEEP
114
What are the diagnostic criteria of ARDS?
Acute onset
Bilateral infiltrates on CXR
Pulmonary artery wedge pressure \< 18 mmHg
Severe hypoxemia PaO2/FiO2 \< 200 mmHg
115
What are the diagnostic criteria for PMS (4)?
116
117
What is the cut-off size for single procedure removal of a sumucosal fibroid by hysteroscopy?
(#321)
Fibroid \< 5 cm
For larger fibroids, repeat procedures are often required
118
For abdominal myomectomies, what kind of uterine incision should be used in priority?
(#321)
**Anterior incision** to minimize adhesions
Posterior incision: 94% adhesion
Anterior incision: 55 %
119
What are the timing criteria associated with PMS ?
(UpToDate)
What are associated symptoms?
Onset **within 5 days** of onset of menses (no end point)
Repetitive for **at least 3 consecutive cycles**
1-4 symptoms that are either physical, behavioral, affective/psychological
≥ 5 physical or behavioral symptoms
----
**_Affective symptoms :_**
* **Irritability = most common**
* Depression, anxiety, sensitivity to rejection, food craving, ↓ interest in activities
**_Physical symotoms:_**
* **Bloating + extreme fatigue = most common**
* Breast pain, swelling, HA, diziness
* **Hot flashes (highly suggestive of PMS or PMDD if not peri menopause)**
120
What are treatment options for PMS/ PMDD (4)?
Exercice/ relaxation (PMS)
Vitex Agnus Castus (Chasteberry) 20 - 40 mg daily (PMS)
If contraception needed: GnRH agonists / OCP
If no contraception: SSRI (continous, cyclical - D14 or onset of symptoms)
121
What is the difference between PMS and PMDD ?
Severe form of PMS where symptoms of anger, irritability and internal tension are prominent
Long list of DSM5 symptoms
Symptoms x 1 year
122
What organic issue is important to R/O before giving a dx of PMS?
Hypo/ Hyper T4
123
Name the absolute contra-indications to MA with MTX/MISO (8)
(#332)
Confirmed or suspected ectopic pregnancy
Anemia with Hb \< 95
IUD
IBD
Active liver of renal disease
Hemorrhagic disorders or using concurrent anti-coag therapy
Known hypersensitivity MTX, MISO
Ambivalent
124
Name the absolute contra-indications to MIFE/MISO (7)
(#332)
Ectopic pregnancy
Chronic adrenal failure
Potent anti-glucocorticoid
Uncontrolled asthma
Inherited porphyria
Known hypersensitivity to the ingredients
Ambivalence
125
Until what GA can MIFE/MISO be used?
What about MTX/MISO
(#332)
MIFE/MISO : 49 days (70)
MTX/MISO: 63 days
126
Name the relative CI to MIFE/MISO MA (5)
(#332)
Unconfirmed GA
IUD
Concurrent long-term systemic corticosteroids
Hemorrhagic disorder
Concurrent anti-coagulation
127
What is the mean number of day to completion of abortion for MTX/MISO and MIFE/MISO (375)?
MIFE/ MISO: 3.3 days
MTX/ MISO: 7.1 days
128
When does fetal RBC start expressing Rh antigen
52 days from LMP
129
What should you do before scheduling a MA (6+1)?
(#332)
CBC
Beta hCG
Ultrasound
Blood group
STI screening or prophylaxis (gono/chlam)
Removing of IUD prn
Liver enzymes/ Renal function if MTX
130
What is the rate of D+C after medical abortion with MIFE
(#322)
3-5 %
131
How long after MA does fertility returns?
(#332)
20 days +/- 5 days
| (ovulation as early as 8 days)
132
What size canula should be used for surgical abortions?
(#360)
**# of complete weeks** or **1 mm smaller**
| (9+6 weeks = 9 weeks)
133
How should beta evolve to confirm a successfull MA ?
(#332)
Fall in beta of 80 % from pre-treatment to 7-14 d post Rx
134
Does anticoagulation need to be stopped prior to surgical T2 abortion?
(#360)
no until GA = 84 days (12 weeks)
135
What are the 3 conditions for lactational amenorrhea method ?
What is the rate of efficacy?
(contraception part 4)
\< 6 months post partum
Fully or nearly fully breastfeeding
Remained amenorrheic
If these 3 conditions are fulfilled → 98 %
136
What is the most common method of contraception in Canada?
(contraception part 5)
Male condoms
137
What is the % reduction of HIV transmission with male condoms?
(part 5)
80 %
138
List contraindications to permanent sterilization (7)
(part 6)
Systemic health problem --\> risk of anesthesia
Pregnancy (unless immediate PP or post abortion)
Current or recent PID (within 3 months)
Cervical, ovarian, endo ca
GTN
Known allergy to contrast media (for Essure)
Uncertain about permanency
139
140
141
Uterine malformation and RPL. Rank in order of importance
(Berghella OB)
Septate (SAB rate = 65%) \> didelphis \> Bicornuate
Arcuate = not associated with RPL
142
Wickham striae are associated with which disease?
**Lichen planus**
Involves vagina
Also linked to ulcers of mucus membranes, flexor surfaces
Tx: steroids, tacrolimus
Systemic: steroids, azathioprine, cyclosporine, hydroxychloroquine
