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Flashcards in Gynae 2 Deck (88)
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1

What is PID

infection of the upper genital tract. Infection spreads upwards from the endocervix causing one or more of:
Endometritis.
Salpingitis.
Parametritis.
Oophoritis.
Tubo-ovarian abscess.
Pelvic peritonitis.

2

What causes PID

Chlamydia trachomatis (14–35% of cases)
Neisseria gonorrhoeae (2–3% of cases)
Mycoplasma genitalium

Organisms in normal vaginal flora (such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) have also been implicated.

3

What are some risk factors for PID

Factors related to sexual behaviour, such as:
<25
Early age of first coitus.
Multiple sexual partners.
New partner within least 3 months
History of STI in the woman or her partner.

Recent instrumentation of the uterus or interruption of the cervical barrier, such as due to:
TOP
Insertion of an intrauterine device
Hysterosalpingography.
IVF and intrauterine insemination.

4

What are the symptoms of PID

asymptomatic
Lower abdominal pain
Deep dyspareunia
PCB
menorrhagia, dysmenorrhoea or IMB
Dysuria (painful urination)
Abnormal vaginal discharge (especially if purulent or with an unpleasant odour)

fever and N+V if severe

5

What are the signs of PID on examination

Lower abdominal tenderness (usually bilateral).
Adnexal tenderness
cervical motion tenderness,
or uterine tenderness
Abnormal cervical or vaginal mucopurulent discharge

6

What investigations should be considered in PID

Pregnancy test, urine dip
FBC, CRP, ESR, GIV, syphilis
Endocervical swabs - gonorrhea and chlamydia,
high vaginal swab - trichomonas vaginalis and bacterial vaginosis

7

How is PID managed

immediate start of 14-day course of broad spectrum antibiotics - Ceftriaxone 500 mg IM, oral doxycycline 100 mg BD and oral metronidazole 400 mg BD for 14 days.

avoid sexual intercourse until the antibiotic course is complete and partner(s) are treated.
All sexual partners from the last 6 months should be tested and treated to prevent recurrence and spread of infection.

8

How should a woman with diagnosed PID be followed up?

R/V in 72 hours
should be clinical improvement. if not, consider admission or review the diagnosis.

Check the antibiotic sensitivities from swab result and adjust antibiotics treatment if necessary.
Continue treatment even if swabs are negative.

R/V in 2-4 weeks to check:
compliance with, and response to, treatment.
Confirm that sexual contacts have been screened and treated.
Discuss the potential sequelae of PID
Ensure repeat pregnancy test, if clinically indicated

9

What are the long term complications of PID

Tubal infertility.
Ectopic pregnancy.
Chronic pelvic pain.
Tubo-ovarian abscess.
Fitz-Hugh Curtis syndrome

10

What is an ovarian cyst

fluid filled sac within the ovary

11

What is the difference between a simple and complex ovarian cyst

simple - fluid only

complex - not simple! may contain blood, solids, septation or vascularity

12

Name some non-neoplastic types of ovarian cysts

follicular
corpus luteal
endometriomal
PCOS
theca lutein

13

Name some benign neoplastic types of ovarian cysts

serous cystadenoma
mucinous cystadenoma
benign cystic teratoma - germ cells
benign mature teratoma - germ cells
fibroma

14

What are the risk factors for ovarian cyst formation

obesity
tamoxifen
early menarche
infertility

15

What are the symptoms of ovarian cysts

dull ache or pain in lower abdomen
dyspareunia
swollen abdomen
pressure effects - frequency

if torsion - severe pain
if rupture - pain, peritonitis, shock

16

What investigations should be done in ovarian cysts

pregnancy test, urine dip
FBC CA125 AFP BhCG
TVUS
FNA and cytology of cyst

17

When should ca125 not be done for an ovarian cyst

for premenopausal women who have a simple cyst on ultrasonography

18

When should AFP and betahCG be done for an ovarian cysts

if it is a germ cell tumour and the woman is under 40

19

What is the RMI in relation to ovarian problems

risk of malignancy index

20

How is the RMI calculated

ultrasound score x menopausal score x CA 125 level in U/mL.

The ultrasound score is the number of the following findings on scan: multilocular cyst, solid areas, bilateral lesions, ascites, intra-abdominal metastases. (0 = no abnormalities, 1 = one abnormality, 3 = two or more)

menopausal score is where 1 = premenopausal and 3 = postmenopausal).

21

How are ovarian cysts managed

expectant - if simple <50mm. repeat TV US in 6 weeks - if persistent then monitor with ultrasound and CA125 3-6 monthly and calculate RMI.

surgery - if persistent and 5-10cm, symptomatic or complex

22

How is the RMI used in management of ovarian cysts

in postmenopausal women:

Low RMI (less than 25): follow up for 1 year with ultrasound and CA125 if less than 5cm.

Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).

High RMI (over 250): referral for staging laparotomy

23

State the different kinds of ovarian cancer

epithelial - 90%
germ cell
sex cord stromal

24

What are the risk factors for ovarian cancer

age

lifestyle:
smoking
obesity
asbestos exposure
low exercise

hormonal:
infertility, clomifene, nulliparity, early menarche, late menopause, HRT

FH
BRCA1/2
endometriosis
history of breast, ovarian or bowel cancer

25

What are the symptoms of ovarin cancer

abdominal discomfort
abdo distention or bloating
frequency
dyspepsia
any new IBS if >50Y
fatigue, weight loss, anorexia, depression
pain - late sign
ascites
breathlessness - pleural effusion
PMB

26

What investigations should be done in suspected ovarian cancer

ca125, AFP, beta hCG
TV USS/ abdo US
CT AP
staging laparotomy

27

What can cause a raised ca-125

ovarian cancer
PID
pregnancy
torsion, rupture or haemorrhage of ovarian cyst
other cancer
trauma
heart failure

28

What are the management options for ovarian cancer

surgery
chemo - cisplatin

29

What is chronic pelvic pain

Intermittent or constant pain in the lower abdomen or pelvis in women.
Lasting for at least six months.
Not occurring exclusively with menstruation or sexual intercourse.
Not being associated with pregnancy.

30

What can cause chronic pelvic pain

Endometriosis:
Adhesions:
IBS.
Interstitial cystitis.
Musculoskeletal problems.
Pelvic organ prolapse.
Nerve entrapment:
Psychological and social issues