Flashcards in Obstetrics and Gynaecology 3 Deck (50):
What are the types of endometrial CA?
Type 1: oestrogen sensitive the majority associated with obesity though usually a less aggressive CA. Atypia are a precursor
Type 2 High grade, clear cell, serious or carcinosarcoma which are more aggressive and not oestrogen sensitive and not associated with obesity.
What is the average age of endometrial CA?
What are the risk factors for endometrial CA?
What are some protective factors?
Endogenous oestrogen excess
- PCOS if prolonged amenorrhoea leads to unopposed E2 action
- Early Menarche
- Late menopause
- unopposed E2 therapy
- tamoxifen (an agonist in the post menopausal uterus - risk especially if used for 5 years)
Lynch type II syndrome (Hereditary Non-Polyposis Colonic Cancer HNPCC - associated with colon, ovarian and endometrial cancer)
Pregnancy and the COCP are protective
What is the mechanism for E2 causing endometrial CA?
Unopposed E2 can cause hyperplasia of the endometrium further stimulation causes abnormalities of the cellular and glandular architecture causing atypia.
Signs and symptoms of endometrial CA?
Postmenopausal bleeding, (10% CA risk)
Premenopausal irregular or intermenstrual bleeding or occasionally recent onset menorrhagia
atrophic vaginitis may coexist.
What is the grading and staging of Endometrial CA?
1 - confined to the uterus
2 - uterus + cervix
3 - within the pelvis
4 - metastasis (liver)
G1 well differentiated
G3 not well differentiated
What stage do most of people with endometrial CA have?
What is the management?
Whats the recurrence like?
Surgical - Bilateral salpingo-oopherectomy - BSO
Lymphadenectomy is not useful in early disease
High risk patients may require adjuvant therapy
Vaginal Vault Radiotherapy
Recurrence is most common at the vaginal vault - normally in the first three years
Worst prognosis is for those with advancing age, advanced stage and grade with adenosquamous histology.
What is a leiomyoscaroma?
A malignant fibroid which presents with rapid, painful uterine fibroid enlargement.
At what endometrial thickness would there be a problem in a post menopausal woman?
> 4 mm
What is the gold standard method of assessment in a woman with Post Menopausal Bleeding?
Hysterscopy and directed biopsy.
Though TV USS and triage based on endometrial thickness allows a proportion of women to be discharged without further investigation.
If a patient with post menopausal bleeding has a biospy and it comes back with endometrial CA positive, what do they need?
Referral to the gynaeoncology MDT.
What are some possible causes of Post Menopausal Bleeding?
Exogenous oestrogens (HRT)
Atrophic Endometritis and Vaginitis
Endometrial or Cervical Polyps
Endometrial hyperplasia with atypia (20%)
Ovarian oestrogen secreting tumour
What is the menopause?
Amenorrhoea for >12 months and not on contraception
Or symptoms in those without a uterus
Average age in the UK is 51
What are the signs and symptoms of the menopause?
- Vasomotor (hot flushes, usually affecting the upper body 8-15 x per day and sweats; especially at night) - resolving after 3 - 5 years.
- Urogenital [genitourinary syndrome of menopause] (Vagina, urethra and bladder trigone are oestrogen dependent and gradually atrophy. Atrophy of the vagina may cause severe superficial dyspareunia and bleeding. Many couples avoid sex because of this. The lack of glycogen causes a rise in vaginal pH from 4.0 to 7.0 increasing risk of infection.
Reduced elasticity of the bladder produces the frequency, urgency, nocturia . incontinence and recurrent infection.
- Osteoporosis (reduced bone mineral density and bone quality- increased risk of vertebral fractures, neck of femur and distal forearm (colles) - time taken to reach the threshold depends on peak bone mass and rate of bone loss. Unregulated osteoclastic activity (osteoblasts are stimulated by oestrogens).
1 in 3 over 50 have 1 or more fractures. A T score is the number of standard deviations away from the normal young mean (+1/-1) osteopenia is -1 to -2.5 osteoporosis is -2.5
- Psychological: irritability, confusion, lethargy, memory loss, loss of libido, depression.
What is normal vaginal discharge?
What is abnormal discharge?
What are the infections commonly associated with vaginal discharge?
- mucoid, characteristically associated with ovulation, to opague.
- It increases around ovulation, during pregnancy and in women taking the combined oral contraceptive.
Exposure of columnar epithelium in cervical eversion and ectropion may cause discharge.
Abnormal discharge is associated with symptoms, which include:
- superficial dyspareunia
- vulval problems
The common infections:
- Bacterial Vaginosis (Gardnerella Vaginalis)
- Trichomoniasis (STI)
- aerobic vaginitis
- atrophic vaginitis
- mucoid cervical ectopy
- foreign body
Where is the normal ovary?
What is it's associated anatomy?
in the ovarian fossa on the lateral pelvic wall
overlying the ureter
attached to the broad ligament by the mesovarium
attached to the pelvic side wall by the infundibulopelvic ligament
attached to the uterus by the ovarian ligament
Blood supply is by the ovarian artery but there is anastomosis with branches of the uterine artery in the broad ligament
When does the fetoplacenta take over?
week 7 to 9
What are ovarian cysts?
What are there classifcations?
a fluid containing structure more than 30 mm in diameter.
May be caused by physiological, infectious, benign, malignant or metastatic
Physiological: development due to exaggerated response to normal physiology includin:
- corpus luteum
- theca lutein cysts
Benign neoplastic: excessive growth of normal ovarian tissue without dysplasia:
- serous cystadenoma
- mucinous cystadenoma
- mature cystic teratoma [dermoid]
- Brenner's tumour
- serous cystadenocarinoma
- mucinous cystadenocarinoma
- endometroid adenocarinoma
- immature teratoma
What are some complications of ovarian cystic disease
rupture, torsion and haemorrhage into a a cyst.
What are the risk factors for ovarian cysts?
- early menarche
What is the management for ovarian cysts?
Depends on the cyst
Expectant with serial ultrasound follow up
Laparoscopic investigation +/- histopathology
Define urinary incontinence
Involuntary urinary leakage which can be divided broadly into
- stress incontinence
- urge incontinence
What is day time frequency?
The number of times a women voids during the day - normal is between 4 and 7 times. Increased frequency is when the women identifies it as too much.
What is nocturia?
Waking at night one or more times to void. Up to the age of 70 years, more than a single void is considered normal.
What is nocturnal enuresis?
Urinary incontinence during sleep
What is urgency?
the compelling desire to pass urine, which is frequently secondary to detrusor overactivity, although inflammatory bladder conditions such as interstitial cystitis (Painful bladder syndrome) may also present with this.
What are common investigations for uro-gynae?
- blood (carcinoma or calculi)
- glucose (diabetes)
- protein (nephrotic?)
- leucocytes (Infection)
- nitrites (infection - send for microscopy and sensitivity)
Record keep for a week with the time, volume of fluid intake and micturition - information about drinking habits, frequency and bladder capacity
URODYNAMIC STUDIES, CYSTOMETRY:
measures the vesical pressure while the bladder is filled and provoked with coughing.
A pressure transducer is also placed in the rectum or vagina to measure abdominal pressure. (subtracting to two gets the true detrusor pressure) - can idenitify urodynamic stress incontinence USI (coughing without detrusor activity) or detrusor overactivity where involuntary destrusor contraction occurs.
Excludes incomplete bladder emptying, congenital abnormalities, calculi and tumours, cortical scaring of the kidneys.
ABDOMINAL X-RAY -KUB
CT UROGRAM W/ CONTRAST
METHYLENE DYE TEST: blue dye into the bladder and leakage checked
visual inspection but little indication of bladder performance
What is the puerperium?
the Pu-er-perium is the period of 6 weeks after birth.
What is Stress Urinary Incontinence?
Stress Urinary Incontinence is the involuntary leakage of urine during exercise or movements such as coughing, sneezing and laughing.
It is caused by weak or damaged muscles and connective tissues in the pelvic floor, compromising urethral support, or by weakness of the urethral sphincter itself.
What is the aetiology of stress urinary incontinence?
:due to weakening and stretching of the muscles and connective tissue during delivery, as well as damage to the pudendal and pelvic nerves.
:due to increased pressure on pelvic tissues over time causing stretch and weakening.
strenuous activity, e.g. weightlifting increases stress on the pelvic support structures.
in the normal woman, when abdominal pressure rises there is an equal compression on the bladder neck. But with weak support it may slip below the pelvic floor and it will not be compressed. If the rest of the urethra and pelvic floor cannot compensate the bladder pressure will exceed the urethral pressure and cause incontinence.
What examination would be formed on a lady with urinary incontinence?
Palpation of the bladder to check for retention
Check for anterior or posterior prolapse and urinary continence
digital examination to confirm pelvic floor muscle contraction
What is the management for stress urinary continence?
Management of lifestyle factors
- Obesity - lose weight
- Cough - prevent smoking to reduce coughing
- reduce excessive fluid intake
1) Trial of pelvic floor muscle training for at least 3 months as a first line treatment for stress or mixed UI (NICE)
It should include at least 8 contractions performed 3 times per day
2) In women who prefer pharmacological to surgical treatment or aren't suitable for surgical treatment Duloxetine is an option (SNRI) that enhances urethral striated sphincter activity. Nausea occurs in up to 1/4 and dyspepsia, dry mouth, dizziness, insomnia or drowsiness can limit its use.
3) surgical management:
- synthetic mid-urethral tape (tension-free vaginal tape TVT and transobtutrator tape TOT) 90% success.
A polypropylene sling is inserted.
- open colposuspension
- autologous rectus fascial sling
4) intramural bulking agents/injectable periurethral bulking agents - lower success but okay if surgery has failed.
What is urge urinary incontinence
What condition is it associated with?
The involuntary leakage of urine accompanied by, or immediately preceded by, a strong desire to pass urine.
Urgency, with or without urge urinary incontinence, usually with frequency and nocturia is also defined as overactive bladder syndrome.(in the absence of infection)
what is the cause of over active bladder?
what is the mechanism?
1) most commonly idiopathic
2) It can follow pelvic surgery and for incontinence
3) Neurogenic causing involuntary detrusor contractions: multiple sclerosis, spina bifida4
4) increases as you get older
The contracting detrusor is felt as urgency, it may over come urethral pressure: urge incontinence. This can occur spontaneously or with provocation - e.g. cold weather, opening the front door, or hearing running water, or coughing - the latter may cause a misdiagnosis of stress incontinence.
What investigations are indicated for urge incontinence
1) bladder diary -? late night drinking and high caffeine intake
2) urine dip and culture
What is the management of overactive bladder/ urge incontinence?
- reduce fluid intake
- reduce caffeine intake
- review diuretics, antipsychotics (antimuscarinic side effects)
- lose weight
Bladder retraining for 6/52 minimum
- timed voiding with systematic delay in voiding
- positive reinforcement
- anticholinergics (which suppress the detrusor activity by blocking the muscarinic receptors (Parasympathetic) that mediate contraction - dry mouth, constipation, nausea, dyspepsia, flatulence, blurred vision, dizziness and insomnia, palpitation, arrthymia as a side effects
oxybutynin tolterodine darifenacin
Consider vaginal oestrogens in postmenopausal women
MDT referral before surgery/botulinum
What are the different kinds of female genital prolapse?
Anterior wall: - Bladder (cystocoele) and/or urethra (urethrocoele)
Apical: Uterus, cervix and upper vagina; vaginal vault if previous hysterectomy
Rectum (rectocoele) and/or pouch of douglas (eneterocooele (loop of small bowel)
What is the aetiology of prolapse?
Vaginal delivery and pregnancy: NVD can cause mechanical injuries and denervation of the pelvic floor: which are increased with large infants, prolonged second stage and instrumental delivery.
Congenital factors: abnormal collagen (Ehlers-Danlos)
Chronic factors: obesity, chronic cough, constipation, heavy lifting or pelvic mass.
Iatrogenic factors: e.g. hysterectomy.
Symptoms of prolapse?
Often absence, but a dragging sensation or sensation of a lump is common. Usually worse at the end of the day or when standing.
treatment for prolapse?
Ring or shelf pessary
changed every 6 - 9 months
Hysteroplexy - attaches the uterus and cervix to the sacrum with mesh
Why are pregnancy women at risk of urinary tract infections?
What should be done?
Dilation of the upper renal tract and urinary stasis due to pressure by the uterus.
Women should be screened for asymptomatic bacteriauria with MSU sample at booking.
What are the symptoms of cystitis?
What about pyelonephritis?
- urinary frequency
- suprapubic pain
- loin and abdominal pain
What are the investigations for urinary tract infections?
Urinalysis - nitrites and leukocytes
MSU - >10x10^4
Bloods: culture, FBC U&E, CRP in pyrexial patient
Renal USS: to exclude hydronephrosis, congenital abnormality and calculi
What is miscarriage?
The fetus dies or delivers dead before 24 completed weeks of pregnancy
The majority occur before 12 weeks.
What are the different types of miscarriage?
Bleeding but the fetus is still alive, the uterus is the size expected from the dates and the cervical os is closed 1/4 will go on to miscarry.
Inevitable miscarriage: bleeding is usually heavier. Although the fetus may be alive, the cervical os is open. Miscarriage is about to occur.
Some fetal parts have been passed but the os is usually open
All fetal tissues have been passed. Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed. USS confirms endometrial thickness <15 mm
The contents of the uterus are infected, causing endometritis. Vaginal loss is usually offensive, the uterus is tender, but a fever can be absent. If pelvic infection occurs there is abdominal pain and peritonism.
The fetus has not developed or died in utero, but this is not recognized until bleeding occurs or ultrasound is performed. The uterus is smaller than expected from the dates and the os is closed.
What factors do not cause miscarriage?
What is the normal history for miscarriage?
Bleeding, unless a missed miscarriage at USS
Pain from uterine contractions can be confused with ectopic pregnancy.
What is the effect on hCG of a viable pregnancy?
hCG levels should increase by >63% in 48 hours.
What is the emergency management for miscarriage?
Admission if the bleeding is heavy or ectopic pregnancy is suspected
Conception products in the cervical os cause pain, bleeding and vasovagal shock and are removed via a speculum using polyp forceps.
Intramuscular ergometrine will reduce bleeding by contracting the uterus, but only if the fetus is non via.
Consider Anti-D in rhesus negative mothers