Gynaecology case discussions

Gynaecology Case Discussions

This is your go-to place to get really good at Gynaecology case discussions, made just for your exams. This page breaks down the most common and important women’s health cases into easy-to-understand questions and answers. We focus on what examiners really want you to know. Learn how to figure out what’s wrong. Understand what tests to do and why. Discover how to treat, and learn what problems might come up. Start learning, and feel ready to ace your clinical exams!

Gynaecology Long Case: Pelvic Organ Prolapse

Patient Summary

A 65-year-old woman, a retired manual worker, presents to the gynaecology clinic with a one-year history of a ‘lump coming down’ from her vagina. She has had 6 normal vaginal deliveries. The lump is more noticeable at the end of the day. She reports urinary frequency and a feeling of incomplete bladder emptying. She denies any urinary leakage. Her bowels are regular. She is not sexually active.

How would you approach the initial assessment of this patient?

My assessment would be systematic, beginning with a detailed history, followed by a focused examination and relevant baseline investigations.

  1. Detailed History Taking:
    • History of Presenting Complaint: I would clarify the nature of the “lump,” asking about its onset, duration, and any change over time. I’d ask what makes it better or worse (e.g., lying down, standing for long periods). I’d assess its impact on her quality of life.
    • Urinary Symptoms: I’d take a detailed history of her storage symptoms (frequency, urgency, nocturia) and voiding symptoms (hesitancy, poor stream, feeling of incomplete emptying). I would specifically ask about stress urinary incontinence.
    • Bowel Symptoms: I would ask about constipation, straining, and any need to digitally support the perineum to defecate (‘splinting’).
    • Gynaecological History: A full obstetric history is crucial, including the number and mode of deliveries, birth weights of babies, and any complications like instrumental delivery or perineal tears.
    • Past Medical and Surgical History: I’d ask about conditions that increase intra-abdominal pressure like chronic cough (COPD, asthma) and any previous pelvic surgeries.
  2. Clinical Examination:
    • General Examination: I would assess her Body Mass Index (BMI).
    • Abdominal Examination: To rule out any pelvic masses that could be contributing to her symptoms.
    • Pelvic Examination: With a chaperone present and with the patient’s consent, I would perform an inspection of the vulva at rest and on coughing/straining to visualise the prolapse. I would then use a Sims’ speculum to systematically assess the anterior and posterior vaginal walls for any associated cystocele or rectocele. Finally, a bimanual examination would be done to assess the size and mobility of the uterus and to check for any adnexal pathology.
  3. Initial Investigations: I would request a urine dipstick test to exclude a urinary tract infection, which can cause or exacerbate urinary symptoms.
Source: Gynaecology by Ten Teachers, 21st Edition; NICE guideline [NG123] – Urinary incontinence and pelvic organ prolapse in women: management.
On examination, you find a second-degree uterine prolapse with a moderate cystocele. What are the management options you would discuss with her?

The management plan should be patient-centred, taking into account her symptoms, examination findings, and personal preferences. I would discuss both conservative and surgical options.

1. Conservative Management (First-line):

  • Lifestyle Modification: Advising on weight management if her BMI is elevated and managing constipation with dietary advice are important first steps.
  • Supervised Pelvic Floor Muscle Training (PFMT): As per NICE guidelines, I would recommend a trial of supervised PFMT for at least 3 months. This is the first-line treatment and can significantly improve symptoms and the degree of prolapse.
  • Vaginal Pessaries: If PFMT is unsuccessful or the patient prefers not to exercise, a vaginal ring pessary is an excellent option. I would explain that it is a device inserted into the vagina to support the uterus and bladder. It requires changing every 4-6 months in the clinic. I would counsel her about the potential for increased vaginal discharge or, rarely, ulceration.

2. Surgical Management:

  • Indications: Surgery is considered if conservative options fail, are not tolerated, or if the patient prefers a definitive treatment from the outset.
  • Procedures: The standard surgical procedure for this patient would be a Vaginal Hysterectomy with an Anterior Repair (for the cystocele). I would explain that this involves removing the uterus through the vagina and repairing the weakened supportive tissues. I would also mention that uterine-preserving surgeries are available but may have a slightly higher recurrence rate.
Source: NICE guideline [NG123] – Urinary incontinence and pelvic organ prolapse in women: management; RCOG Green-top Guideline No. 46 – The Management of Post Hysterectomy Vault Prolapse.
What are the potential complications of a Vaginal Hysterectomy and Repair that you must discuss during the consent process?

Informed consent is a crucial process. I would discuss the risks in categories to ensure a clear understanding.

Timing Complication Approximate Risk
Intra-operative Significant Haemorrhage (requiring blood transfusion) Common (~1 in 20)
Damage to the Bladder Uncommon (~1 in 100)
Damage to the Ureter or Bowel Rare (~1 in 500)
Conversion to abdominal surgery Rare
Early Post-operative Infection (wound, urine, chest) Common
Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) Uncommon
Urinary retention requiring temporary catheterisation Common
Late Post-operative Recurrence of prolapse (including vault prolapse) ~1 in 10 over lifetime
Painful intercourse (dyspareunia) Uncommon
Development of new urinary symptoms (e.g., stress incontinence) Uncommon
Source: Gynaecology by Ten Teachers, 21st Edition, Chapter 17; RCOG Patient Information Leaflet – Vaginal Hysterectomy.

Gynaecology Long Case: Heavy Menstrual Bleeding with Fibroids

Patient Summary

A 40-year-old mother of 3 presents with a 5-year history of heavy menstrual bleeding with clots. Her periods last for 7-8 days. She denies any intermenstrual or postcoital bleeding. She is currently using condoms for contraception and has completed her family. On examination, she has a non-tender, enlarged uterus, approximately the size of a 14-week pregnancy, which is mobile. An ultrasound scan confirms multiple uterine fibroids, the largest being a 5cm intramural fibroid.

How would you investigate and manage this patient?

My approach would be to confirm the diagnosis, exclude other pathologies, and offer a stepwise management plan according to NICE guidelines, taking into account that she has completed her family.

Investigations:

  1. Full Blood Count (FBC): To check for anaemia, which is common with HMB.
  2. Transvaginal Ultrasound Scan (TVUSS): This has already been done and confirmed fibroids. It is crucial for assessing the size, number, and location (submucosal, intramural, subserosal) of the fibroids, which influences management.
  3. Endometrial Biopsy: Given her age (40 years), an endometrial biopsy is recommended to exclude any underlying endometrial hyperplasia or malignancy, especially before considering certain treatments like endometrial ablation. This can be done via a Pipelle sampler in the outpatient clinic.

Management Options:

I would discuss both medical and surgical options, explaining the pros and cons of each.

  • Medical Management:
    • Levonorgestrel-releasing Intrauterine System (LNG-IUS): This is the first-line medical treatment according to NICE. It is highly effective at reducing bleeding and provides contraception. However, its effectiveness can be reduced by large or submucosal fibroids that distort the uterine cavity.
    • Tranexamic Acid or NSAIDs: These can be used to reduce blood loss but are often less effective when significant fibroids are present.
    • Combined Oral Contraceptives (COCP): Can help regulate the cycle and reduce bleeding.
    • GnRH Analogues: These induce a temporary ‘medical menopause’ and can shrink fibroids. They are typically used for a short duration (3-6 months) pre-operatively to reduce fibroid size and make surgery easier.
  • Surgical Management:
    • Myomectomy: Surgical removal of fibroids while preserving the uterus. This is primarily for women who wish to retain their fertility, so it is less relevant for this patient but should still be mentioned as an option.
    • Uterine Artery Embolisation (UAE): A radiological procedure that blocks the blood supply to the fibroids, causing them to shrink. It is a less invasive alternative to surgery.
    • Endometrial Ablation: A procedure to destroy the lining of the uterus. It is only suitable if there are no large or submucosal fibroids.
    • Hysterectomy: The definitive treatment for HMB when other options have failed or are not suitable. Given that she has completed her family and has symptomatic fibroids, this is a very reasonable option to discuss.
Source: NICE guideline [NG88] – Heavy Menstrual Bleeding: assessment and management; Gynaecology by Ten Teachers, 21st Edition, Chapter 12.
The patient is interested in a hysterectomy. What are the different types of hysterectomy, and which would you recommend?

I would explain that there are different ways to perform a hysterectomy and the best approach depends on factors like uterine size, previous surgeries, and the surgeon’s expertise.

Routes of Hysterectomy:

  • Abdominal Hysterectomy: The uterus is removed through an incision in the abdomen. This is the traditional approach, often required for a large uterus (like this patient’s 14-week size uterus).
  • Vaginal Hysterectomy: The uterus is removed through the vagina. This is preferred when there is an associated prolapse and the uterus is not too large. It has the advantage of no visible scar and a quicker recovery.
  • Laparoscopic Hysterectomy: A keyhole approach. The uterus is detached internally using laparoscopic instruments and then removed through the vagina. This combines the benefits of minimal scarring and faster recovery. For a 14-week size uterus, this might require morcellation (cutting the uterus into smaller pieces) to remove it, which carries a small risk of disseminating an unsuspected sarcoma.

Extent of Hysterectomy:

  • Total Hysterectomy: Removal of the uterus and cervix. This is the standard procedure.
  • Subtotal Hysterectomy: Removal of the uterus, leaving the cervix behind. This may be associated with a slightly lower risk of bladder or bowel injury but requires ongoing cervical screening.

Recommendation for this Patient:

Given the 14-week size of her uterus, a Total Abdominal Hysterectomy is the most likely and safest option. A laparoscopic approach might be possible but would depend on the surgeon’s skill and would need a detailed discussion about morcellation. I would also discuss a bilateral salpingectomy (removal of fallopian tubes) at the time of hysterectomy to reduce her future risk of ovarian cancer, as recommended by RCOG. The decision to remove the ovaries (oophorectomy) would be a separate discussion based on her age and risk factors.

Source: Gynaecology by Ten Teachers, 21st Edition, Chapter 17; RCOG Patient Information Leaflets.
“`html

Gynaecology Long Case: Urinary Incontinence

Patient Summary

A 45-year-old multiparous woman presents with symptoms of mixed urinary incontinence, worsening over the past 6 months. She reports involuntary leakage of urine with coughing, sneezing, and lifting heavy objects (stress component), as well as a strong, sudden urge to urinate followed by involuntary leakage, sometimes before reaching the toilet (urge component). She had a normal vaginal delivery 2 years ago. She is obese with a BMI of 32 kg/m$^2$. She denies any fever, dysuria, haematuria, or foul-smelling discharge. She also denies any other abdominal or pelvic pain, or difficulty with bowel movements. There is no significant past medical history and no family history of similar conditions.

How would you approach the history taking for this patient with mixed urinary incontinence?

My history taking would focus on thoroughly characterising her incontinence, identifying contributing factors, and assessing its impact on her quality of life.

Key Areas of Inquiry:

  • Nature of Incontinence (Detailed SOCRATES for leakage):
    • Onset, Duration, Progression: When did it start? How has it changed?
    • Type of Leakage: Differentiate stress from urge. Ask specifically about leakage with cough, sneeze, laugh, lift (stress), and leakage with sudden urge before reaching toilet, or without obvious trigger (urge).
    • Frequency and Severity: How often does leakage occur? What volume of urine is lost? How many pads per day?
    • Triggers: What activities or situations lead to leakage?
    • Associated Symptoms:
      • Urinary Symptoms: Frequency (day/night), urgency (with or without incontinence), dysuria, haematuria, sensation of incomplete emptying, straining to void.
      • Bowel Symptoms: Constipation, faecal incontinence (common co-morbidity).
      • Pelvic Organ Prolapse Symptoms: Sensation of a bulge or ‘something coming down’, drag sensation.
      • Neurological Symptoms: Numbness, weakness, back pain (to rule out neurological causes).
  • Obstetric History:
    • Parity, Mode of Delivery: Number of vaginal deliveries, instrumental deliveries, large babies. Significance: Vaginal delivery is a major risk factor for stress urinary incontinence (SUI) due to pelvic floor muscle and nerve damage.
    • Complications of Deliveries: Perineal tears (especially 3rd/4th degree), prolonged second stage.
  • Gynaecological History:
    • Menstrual Status: Pre- or post-menopausal. Significance: Oestrogen deficiency in menopause can worsen symptoms of overactive bladder (OAB) and SUI.
    • Previous Surgeries: Pelvic surgeries (e.g., hysterectomy, previous incontinence surgery).
    • Chronic Pelvic Pain or Dyspareunia.
  • Past Medical History:
    • Co-morbidities: Diabetes Mellitus, neurological conditions (stroke, Parkinson’s, multiple sclerosis), chronic cough (e.g., asthma, COPD), obesity, previous pelvic radiotherapy. Significance: DM can cause polyuria or diabetic neuropathy. Neurological conditions can cause neurogenic bladder. Chronic cough increases intra-abdominal pressure. Obesity increases intra-abdominal pressure and is a significant risk factor for SUI.
    • Current Medications: Diuretics, sedatives, alpha-blockers (can cause stress incontinence), anticholinergics (can cause retention).
  • Social History:
    • Occupation: Any heavy lifting?
    • Lifestyle: Smoking (chronic cough), caffeine and alcohol intake (bladder irritants).
    • Fluid Intake: Excessive or insufficient.
    • Impact on Quality of Life: How does incontinence affect her daily activities, social life, work, psychological well-being, and sexual function? This is crucial for guiding management decisions.
  • Family History: Incontinence, pelvic organ prolapse.
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
What key findings would you look for on general and abdominal examination, and what is their significance, including relevant negative findings?

The examination aims to identify general risk factors, look for signs of co-existing conditions, assess the pelvic floor, and elicit signs of incontinence.

General Examination:

  • Weight and BMI: Her BMI of 32 kg/m$^2$ indicates obesity. Significance: Obesity significantly increases intra-abdominal pressure, predisposing to and worsening SUI. Weight reduction is a key conservative management strategy.
  • Gait and Mobility: Assess for neurological deficits or mobility issues that might affect reaching the toilet in time (relevant for urge incontinence).
  • Respiratory System: Auscultate lungs. Significance: Chronic cough (from asthma, COPD, smoking) increases intra-abdominal pressure, worsening SUI. The absence of bronchial breathing and added sounds is an important negative finding, ruling out active lung pathology contributing to chronic cough.
  • Cardiovascular System: Look for ankle oedema (may indicate diuretic use or fluid overload).
  • Neurological Examination (basic): Assess lower limb power, sensation, and reflexes if a neurological cause is suspected.

Abdominal Examination:

  • Inspection: Look for scars (previous surgeries), distension.
  • Palpation: Palpate for masses, tenderness, or a distended bladder (suggesting incomplete emptying or retention, relevant for overflow incontinence).

Pelvic Examination (with chaperone and consent, in lithotomy position):

  • Inspection of Vulva and Perineum: Look for skin excoriation, atrophy (oestrogen deficiency), discharge, or evidence of previous episiotomy scars/perineal tears.
  • Speculum Examination:
    • Assess vaginal walls for atrophy (thin, pale, dry mucosa), inflammation, or obvious fistula (unlikely in mixed incontinence but always considered in leakage).
    • Identify any obvious prolapse (cystocele, rectocele, uterine prolapse) at rest and on straining.
  • Bimanual Examination:
    • Assess uterine size, position, and mobility.
    • Palpate adnexa for masses.
    • Assess for any tenderness.
  • Pelvic Floor Assessment:
    • Ask the patient to voluntarily contract her pelvic floor muscles (as if stopping urine flow). Assess strength, duration, and correct technique of contraction. Significance: Weakness or poor technique indicates a need for pelvic floor muscle training.
  • Cough Stress Test (Stress Incontinence Assessment): This is the key component to demonstrate.
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
How would you specifically assess for stress urinary incontinence during examination?

To specifically assess for stress urinary incontinence (SUI), I would perform a Cough Stress Test.

Procedure for Cough Stress Test:

  1. Ensure the patient has a comfortably full bladder.
  2. Position the patient in the lithotomy position.
  3. Place a pad under the patient to absorb any leakage.
  4. Ask the patient to cough vigorously while observing the urethral meatus.
  5. Significance: Immediate, involuntary leakage of urine synchronized with the cough confirms SUI.
  6. If no leakage occurs with a full bladder, the test can be repeated while standing, as some women only leak in this position.
  7. The test can also be performed with a speculum in place to rule out vaginal wall prolapse obscuring the urethra (Bonney’s test or ‘Q-tip’ test are more specialized variations, but simple cough test is primary). If leakage stops with urethral elevation (e.g., using fingers or a cotton swab), it suggests urethral hypermobility contributing to SUI.
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
What are the different types of urinary incontinence, and how would you initially assess and investigate this patient to determine the predominant type?

Urinary incontinence (UI) is defined as the complaint of any involuntary leakage of urine. It is classified into several types:

Types of Urinary Incontinence:

    [cite_start]
  • Stress Urinary Incontinence (SUI): Involuntary leakage of urine on effort or physical exertion, or on sneezing or coughing[cite: 1]. It is due to urethral sphincter incompetence and/or urethral hypermobility.
    • [cite_start]
  • Urge Urinary Incontinence (UUI): Involuntary leakage of urine accompanied by or immediately preceded by urgency[cite: 1]. Urgency is a sudden, compelling desire to pass urine that is difficult to defer. It is often associated with overactive bladder (OAB) syndrome.
    • [cite_start]
  • Mixed Urinary Incontinence (MUI): Involuntary leakage of urine associated with both urgency and exertion, sneezing, or coughing[cite: 1]. This patient presents with MUI.
  • Overflow Incontinence: Involuntary leakage of urine due to overdistension of the bladder, often due to chronic urinary retention. Can present as continuous dribbling or frequent small voids.
  • Continuous Incontinence: Constant leakage of urine, often suggestive of a fistula (e.g., vesicovaginal fistula) or severe sphincter damage.
  • Nocturnal Enuresis: Involuntary leakage of urine that occurs during sleep.
  • Functional Incontinence: Incontinence due to physical or cognitive impairment preventing a person from reaching the toilet in time.

Initial Assessment and Investigation:

For this patient with mixed incontinence, the initial assessment aims to confirm the diagnosis, quantify the symptoms, and identify factors amenable to conservative treatment before considering further investigations.

  1. Detailed History: As outlined previously, this is paramount for differentiating SUI and UUI components. Key is understanding the triggers, severity, and impact.
  2. Clinical Examination: As outlined previously, including abdominal, pelvic, and specific stress test.
  3. Bladder Diary: This is a crucial non-invasive investigation.
    • Method: The patient records fluid intake, times and volumes of all voids, and episodes of leakage (and associated triggers/urgency) over a period.
    • Duration: Typically maintained for 3 days, including both working and non-working days.
    • Purpose: Provides objective data on voiding patterns, frequency, urgency episodes, and volume of leakage. It helps identify excessive fluid intake, specific bladder irritants (e.g., caffeine), and the relative contribution of urge and stress components.
    • Advices given: Instruct the patient clearly on how to record accurately. Advise them to measure all fluid intake (drinks) and urine output using a measuring jug. Emphasize that all leakage episodes should be marked, along with the trigger.
  4. Urinalysis and Urine Culture: To rule out urinary tract infection (UTI) or haematuria. UTI can cause or exacerbate urgency and incontinence symptoms.
  5. Post-Void Residual (PVR) Volume: Measured by ultrasound scan immediately after voiding. Significance: A high PVR (>100-150 mL) suggests incomplete bladder emptying or outflow obstruction, raising suspicion for overflow incontinence.
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
Describe the non-surgical management options for this patient with mixed urinary incontinence.

Non-surgical management is the first line of treatment for all types of urinary incontinence, especially mixed incontinence. [cite_start]It is often effective and avoids the risks of surgery. [cite: 1]

Non-Surgical Management for Mixed Urinary Incontinence:

  1. Lifestyle Interventions:
    • Weight Reduction: For an obese patient (BMI 32 kg/m$^2$), significant weight loss can substantially reduce symptoms of SUI by decreasing intra-abdominal pressure.
    • Fluid Management: Advise on optimal fluid intake (1.5-2 liters/day unless contraindicated), avoiding excessive intake. Reduce consumption of bladder irritants like caffeine, alcohol, fizzy drinks, and artificial sweeteners.
    • Smoking Cessation: To reduce chronic cough, which exacerbates SUI.
    • Constipation Management: Treat constipation to reduce straining and pelvic floor pressure.
  2. Pelvic Floor Muscle Training (PFMT):
    • Description: Aims to strengthen the muscles of the pelvic floor, which support the bladder and urethra, improving urethral sphincter competence. It is effective for SUI and can also help with urgency.
    • Implementation: Refer to a specialised physiotherapist for supervised PFMT. Patients are taught correct contraction techniques and perform regular exercises (e.g., 8-12 contractions, 3 times a day, sustained for 6-10 seconds).
    • Duration: Recommended for at least 3 months, but ongoing maintenance is often necessary.
  3. Bladder Training (for Urge Component):
    • Description: Aims to increase bladder capacity and reduce urgency by gradually increasing the time between voids.
    • Implementation: Using the bladder diary, the patient gradually extends voiding intervals, starting with manageable increments (e.g., 15-30 minutes). Distraction techniques are used to suppress urgency.
    • Patient Education: Teach techniques to suppress urgency, such as pelvic floor muscle contraction and distraction.
  4. Pharmacological Management (primarily for Urge Component):
    • If lifestyle changes and bladder training are insufficient for the urge component, medications can be considered.
    • Antimuscarinics (e.g., Solifenacin, Tolterodine, Oxybutynin): Reduce detrusor overactivity. Side effects include dry mouth, constipation, blurred vision.
    • Beta-3 Adrenoceptor Agonists (e.g., Mirabegron): Relax the detrusor muscle. Fewer side effects than antimuscarinics, particularly dry mouth.
  5. Vaginal Oestrogen (for post-menopausal women with atrophy):
    • If the patient is post-menopausal and has signs of vaginal atrophy, local vaginal oestrogen can improve bladder neck and urethral mucosal health, benefiting both SUI and UUI symptoms.
  6. Continence Products: Pads or absorbent aids can be used for containment while awaiting or during treatment.
Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
When would you consider surgical management for stress urinary incontinence, and what are the common surgical options? What is the role of urodynamic studies in her management, particularly in the local context (Ragama)?

Consideration for Surgical Management of SUI:

Surgical management for SUI is considered when conservative measures (like pelvic floor muscle training and lifestyle modifications) have failed or are not sufficient to improve symptoms to an acceptable level, and the patient’s quality of life is significantly impacted. [cite_start]It is typically a second-line treatment. [cite: 1]

Common Surgical Options for SUI:

    [cite_start]
  • Mid-Urethral Slings (MUS): This is the most common and widely accepted surgical procedure for SUI. [cite: 1]
    • Retropubic Slings (e.g., TVT – Tension-free Vaginal Tape): Passed from the vagina, behind the pubic bone, and out through the abdominal wall.
    • Transobturator Slings (e.g., TOT – Transobturator Tape): Passed from the vagina, through the obturator foramen, and out through the groin.
    • Mechanism: Both create a hammock-like support under the mid-urethra, preventing descent during increases in intra-abdominal pressure.
    • [cite_start]
  • Burch Colposuspension: A traditional open or laparoscopic procedure that involves suturing the periurethral and paravaginal tissues to Cooper’s ligament to elevate and support the bladder neck and urethra. [cite: 1]
  • Urethral Bulking Agents: Injections of various substances into the tissues surrounding the urethra to increase coaptation. Less invasive, but often less durable than slings, typically reserved for frail patients or those desiring minimal intervention.

Role of Urodynamic Studies in Management:

[cite_start]

Urodynamic studies (UDS) are a group of tests that assess how the bladder and urethra function by measuring bladder pressure, flow rates, and sphincter activity during filling and emptying. [cite: 1]

  • Primary Role: To confirm the diagnosis of SUI, exclude other causes of incontinence (e.g., detrusor overactivity or voiding dysfunction), identify bladder outlet obstruction, and assess bladder capacity and compliance. [cite_start]They provide objective evidence of bladder function. [cite: 1]
  • Indications for UDS (NICE Guidelines recommend prior to surgery for SUI):
    • If there is uncertainty about the diagnosis of SUI or UUI.
    • When conservative management has failed and surgical intervention is being considered.
    • If there is a suspicion of voiding dysfunction or bladder outflow obstruction.
    • In cases of recurrent incontinence after previous surgery.
    • Presence of significant co-morbidities (e.g., neurological disease).
    • In patients with mixed incontinence where the predominant type is unclear, to guide treatment choice (SUI surgery for SUI component, OAB treatment for UUI component).

Urodynamic Studies in Local Context (Ragama):

While Urodynamic studies are standard of care before incontinence surgery in many developed settings (e.g., according to NICE guidelines), their availability can vary in resource-limited settings like Sri Lanka. In Ragama, specific availability of full urodynamic testing would need to be confirmed (e.g., “Do we do urodynamic studies in Ragama?”).

  • If Urodynamic Studies are Available: They would be performed as per standard indications, providing objective data to guide surgical decision-making and predict outcomes.
  • If Urodynamic Studies are NOT Readily Available or Practical:
    • Clinical assessment becomes even more critical. A thorough history (including bladder diary) and examination (including objective cough test, pelvic floor assessment, and PVR) are paramount.
    • Management decisions would rely heavily on these clinical findings. For clear-cut SUI that has failed conservative management, surgery might still proceed based on clinical diagnosis, but with careful patient selection and counselling about potential risks.
    • In cases of mixed incontinence, the predominant symptom would be targeted first (e.g., treating UUI with medication and bladder training, then reassessing SUI). If SUI is still bothersome, a trial of surgery for SUI might be considered.
    • Careful post-operative monitoring for complications like voiding dysfunction is essential without pre-operative UDS data.

Management for Urge Urinary Incontinence (UUI):

[cite_start]

If the urge component remains significant after conservative and pharmacological measures, more invasive treatments can be considered, though these are less common than SUI surgeries. [cite: 1]

  • Botulinum Toxin A (Botox) Injections: Injected into the detrusor muscle to reduce bladder overactivity. [cite_start]Effects last for 6-9 months and require repeat injections. [cite: 1]
    • [cite_start]
  • Sacral Neuromodulation (SNM): Implantation of a device that sends electrical impulses to the sacral nerves, modulating bladder function. [cite: 1]
    • [cite_start]
  • Augmentation Cystoplasty: Surgical enlargement of the bladder using a segment of bowel, reserved for severe, refractory cases. [cite: 1]
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
What are the potential complications associated with surgical interventions for urinary incontinence?

Surgical interventions for urinary incontinence, while generally safe and effective, carry potential risks and complications. These can vary depending on the specific procedure (e.g., mid-urethral sling, colposuspension).

Common and Serious Complications:

  • Intraoperative Complications:
    • Haemorrhage: Bleeding from surgical sites.
    • Organ Injury: Damage to bladder, urethra, bowel, or major blood vessels. Bladder perforation is a known complication of mid-urethral sling insertion.
    • Nerve Injury: Though rare, can occur.
  • Early Postoperative Complications:
    • Urinary Retention: Difficulty or inability to void after surgery, often requiring catheterisation. This can be temporary or, rarely, persistent.
    • Pain: Incision site pain, or less commonly, chronic pain in the groin or pelvis (especially with transobturator slings).
    • Infection: Urinary tract infection (UTI), wound infection, or less commonly, mesh infection (if a sling is used).
    • Haematoma/Seroma formation.
  • Late Postoperative Complications:
    • De Novo Urge Incontinence (UUI) or Worsening of Pre-existing UUI: Surgical correction of SUI can sometimes unmask or worsen urge symptoms.
    • Mesh Erosion/Exposure (specific to sling procedures): The synthetic mesh can erode into the vagina, bladder, or urethra, causing pain, discharge, bleeding, or recurrent UTIs. This is a serious but rare complication.
    • Recurrence of Incontinence: Failure of the procedure to achieve continence, or recurrence of leakage over time.
    • Dyspareunia: Painful intercourse, particularly if vaginal scarring or mesh exposure occurs.
    • Fistula formation: Extremely rare, but communication between the urinary tract and vagina can occur if injury goes unrecognised.
Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
“`

Gynaecology Long Case: Subfertility (Revised)

Patient Summary

A 33-year-old woman and her 35-year-old husband present to the clinic after trying to conceive for 2 years. She has a history of irregular menstrual cycles, occurring every 2 to 3 months. She has a BMI of 31 and notes some excess facial hair. Her husband is fit and well with no significant medical history. They have no children from this or previous relationships.

What are the key components of the history, and what is their significance?

The history is paramount for directing investigations. I would systematically explore factors related to the three main causes of subfertility: ovulatory dysfunction, tubal/uterine factors, and male factors.

For the Female Partner:

  • Menstrual Cycle: The history of cycles every 2-3 months is oligomenorrhoea. Significance: This strongly suggests an ovulatory disorder, which is the most likely primary problem and is a key diagnostic criterion for Polycystic Ovary Syndrome (PCOS).
  • Hyperandrogenism: The complaint of excess facial hair. Significance: This is a clinical sign of hyperandrogenism, another key criterion for PCOS.
  • Past Gynaecological History: I would ask about any history of pelvic inflammatory disease (PID) or symptoms suggestive of it (e.g., severe lower abdominal pain with discharge). Significance: PID is a major cause of tubal factor subfertility.
  • Previous Pelvic Surgery: I’d ask about procedures like appendicectomy or ovarian cystectomy. Significance: These can lead to pelvic adhesions, causing secondary tubal damage.

For the Male Partner:

  • Medical History: I’d ask about mumps orchitis after puberty, testicular trauma, or maldescent. Significance: These can cause primary testicular failure, leading to male factor subfertility.
  • Previous Fertility: I’d ask if he has fathered children previously. Significance: While reassuring, it does not exclude a current issue (secondary infertility).

For the Couple:

  • Coital Frequency and Timing: Significance: Infrequent intercourse or poor timing can be a simple reversible cause.
  • Lifestyle: I would assess BMI, smoking, and alcohol for both partners. Significance: Extremes of BMI and smoking in either partner are known to reduce fertility and the success rates of treatment. The patient’s BMI of 31 is a significant factor.
Source: NICE guideline [CG156] – Fertility problems: assessment and treatment; Gynaecology by Ten Teachers, 21st Edition, Chapter 7.
What are the key clinical findings to look for on examination and their significance?

The examination is focused on identifying signs that support the main differential diagnoses suggested by the history.

Examination of the Female Partner:

  • BMI Calculation: Significance: Her BMI of 31 supports the diagnosis of PCOS and is a modifiable factor that must be addressed as first-line management.
  • Signs of Hyperandrogenism:
    • Hirsutism: I would formally score this using the Ferriman-Gallwey score. Significance: An objective score confirms a key clinical feature of PCOS.
    • Acanthosis Nigricans: Inspecting the axillae and neck. Significance: This is a cutaneous marker of insulin resistance, which is the key metabolic abnormality underlying PCOS.
  • Bimanual Pelvic Examination:
    • Findings: I would assess uterine size and mobility, and palpate the adnexa. The ovaries may be bulky and palpable.
    • Significance: The primary goal is to exclude other pathologies like large fibroids or an endometrioma. A fixed, tender uterus would suggest adhesions or endometriosis, shifting the focus towards a tubal factor.

Examination of the Male Partner:

  • Findings: I would assess testicular volume (using an orchidometer), consistency, and check for the presence of the vas deferens bilaterally.
  • Significance: Small, soft testes suggest primary testicular failure. Absence of the vas deferens indicates obstructive azoospermia. A varicocele may be found, though its role in subfertility is debated.
Source: Gynaecology by Ten Teachers, 21st Edition, Chapter 7.
Your investigations confirm PCOS with anovulation and a normal semen analysis. Tubal patency is also confirmed. Discuss the management plan.

The management plan for anovulatory subfertility due to PCOS is stepwise, focusing on the least invasive methods first, as recommended by NICE.

  1. Lifestyle Modification and Counselling:
    • Weight Management: This is the cornerstone of first-line management. I would explain that her raised BMI is likely contributing to her anovulation. A 5-10% loss of body weight can restore ovulation in over 50% of women. I would refer her to a dietitian.
    • Folic Acid: I would ensure she is taking the recommended dose.
  2. Ovulation Induction (Medical Management): If ovulation does not resume after 3-6 months of lifestyle changes, I would offer medical induction.
    • First-line drug: Letrozole, an aromatase inhibitor. Significance: NICE guidelines now recommend letrozole over clomiphene as it is associated with higher live birth rates in women with PCOS.
    • Second-line drug: Clomiphene Citrate or a combination of clomiphene and metformin.
    • Third-line option: Injections of Gonadotrophins (FSH). Significance: This is more complex, requiring intensive ultrasound monitoring due to the high risk of multiple pregnancy and Ovarian Hyperstimulation Syndrome (OHSS).
  3. Surgical Management:
    • Laparoscopic ovarian drilling is a second-line surgical option for women who are resistant to oral ovulation induction agents.
  4. Assisted Reproductive Technology (ART):
    • In Vitro Fertilisation (IVF) is reserved for women who fail to conceive with ovulation induction or who have other co-existing factors.
Source: NICE guideline [CG156] – Fertility problems: assessment and treatment.

Gynaecology Long Case: Postmenopausal Bleeding (Revised)

Patient Summary

A 55-year-old woman presents to the 2-week-wait clinic with a single episode of postmenopausal bleeding (PMB) that occurred one week ago. Her last menstrual period was 3 years ago. She is not on Hormone Replacement Therapy (HRT). She is otherwise well with a past medical history of type 2 diabetes and a BMI of 32. Her cervical screening history is up to date and normal.

What are the key components of the history, and what is their significance?

The history is essential to assess this patient’s risk of endometrial cancer, which is the primary concern in any case of PMB.

  • The Bleeding Episode: I would ask about the quantity (spotting vs. heavy), duration, and if it was provoked (e.g., post-coital). Significance: While any PMB is abnormal, heavier or persistent bleeding is more concerning. Post-coital bleeding would raise suspicion of a cervical pathology.
  • Risk Factors for Endometrial Cancer: This is a critical line of questioning. I would specifically ask about:
    • Obesity: Her BMI of 32 is a major risk factor. Significance: Peripheral aromatization of androgens to oestrogen in adipose tissue leads to unopposed oestrogen stimulation of the endometrium.
    • Diabetes: Her Type 2 diabetes is another significant risk factor. Significance: It’s associated with hyperinsulinaemia, which also promotes endometrial proliferation.
    • Nulliparity: I would confirm her parity. Significance: Nulliparity is a risk factor due to a lifetime of uninterrupted ovulatory cycles.
    • Menstrual History: Age at menarche and menopause. Significance: An early menarche and late menopause increase the total lifetime exposure to oestrogen.
    • Drug History: Confirm she is not on HRT. I’d also ask about Tamoxifen use. Significance: Unopposed oestrogen in HRT and the oestrogenic effect of Tamoxifen on the endometrium are major risk factors.
    • Family History: I would ask about a family history of endometrial, ovarian, breast, or bowel cancer. Significance: This could suggest an underlying genetic predisposition such as Lynch Syndrome.
  • Other Gynaecological History: A normal cervical screening history makes cervical cancer less likely, but not impossible, as the source of bleeding.
Source: NICE guideline [NG12] – Suspected cancer: recognition and referral; Gynaecology by Ten Teachers, 21st Edition, Chapter 15.
What are the key clinical findings to look for on examination and their significance?

The examination is focused on identifying the source of bleeding and excluding pathologies in the lower genital tract, while also assessing for signs of advanced disease.

  • General Examination:
    • Finding: Assess for signs of anaemia or cachexia.
    • Significance: These are late signs and would be very concerning for advanced malignancy.
  • Abdominal Examination:
    • Finding: Palpate for an enlarged uterus or other pelvic masses.
    • Significance: A palpable mass in a postmenopausal woman is highly suspicious for malignancy (uterine or ovarian).
  • Speculum Examination:
    • Finding: I would carefully inspect the vulva and vagina for atrophic changes (pale, thin, dry mucosa), which is the most common cause of PMB. I’d also look for any suspicious lesions. I would then visualise the cervix to look for polyps or features of cervical cancer. The crucial finding is to confirm if the bleeding is originating from the external cervical os.
    • Significance: Identifying an external cause like atrophic vaginitis or a cervical polyp may provide a simple explanation. Confirming bleeding is from the uterus directs all further investigation to the endometrium.
  • Bimanual Examination:
    • Finding: Assess the size, shape, and mobility of the uterus.
    • Significance: A bulky uterus could suggest fibroids or endometrial cancer. A fixed pelvis is a sign of advanced disease with local infiltration.
Source: Gynaecology by Ten Teachers, 21st Edition, Chapter 2.
The ultrasound shows an endometrial thickness of 12mm. The subsequent biopsy confirms endometrial hyperplasia without atypia. How would you manage this patient?

The management of endometrial hyperplasia depends entirely on the presence or absence of cellular atypia. As this patient has hyperplasia without atypia, the primary goal is to reverse the hyperplasia and prevent progression to atypical hyperplasia or cancer, which occurs in less than 5% of cases over 20 years.

Management Options for Hyperplasia Without Atypia:

  1. Risk Factor Modification: The first step is to address her modifiable risk factors. I would strongly advise and support her with weight loss, as this will reduce the peripheral production of oestrogen. Good glycaemic control for her diabetes is also important.
  2. Progestogen Therapy (First-line): The mainstay of treatment is to provide progestogen to oppose the effect of oestrogen and induce regression of the hyperplasia.
    • Levonorgestrel-releasing Intrauterine System (LNG-IUS): This is the first-line treatment recommended by RCOG. It provides a high local concentration of progestogen directly to the endometrium with minimal systemic side effects. It is highly effective, with regression rates of over 90%. It also provides contraception if needed.
    • Continuous Oral Progestogens: An alternative is continuous oral medroxyprogesterone acetate or norethisterone. Significance: This is considered second-line as it is less effective than the LNG-IUS and has more systemic side effects.
  3. Follow-up and Surveillance:
    • It is mandatory to ensure the hyperplasia resolves. Follow-up endometrial biopsies are required every 6 months until two consecutive negative biopsies are obtained.
    • If the hyperplasia persists after 12 months of treatment, a hysterectomy should be considered.
  4. Hysterectomy: This is not a first-line treatment for hyperplasia without atypia but is an option for women who have completed their family and decline medical management/surveillance, or if the hyperplasia persists despite treatment.

Important Note: If the biopsy had shown atypical hyperplasia, the management would be completely different. Atypical hyperplasia carries a high concurrent risk of underlying cancer (~40%) and a high risk of progression. Therefore, the standard treatment for atypical hyperplasia in a postmenopausal woman is a Total Hysterectomy with Bilateral Salpingo-oophorectomy.

Source: RCOG/BSGE Green-top Guideline No. 67 – Management of Endometrial Hyperplasia.

Gynaecology Long Case: Dysmenorrhoea & Endometriosis

Patient Summary

A 33-year-old woman, married for 10 years, presents with a 3-year history of worsening cyclical pelvic pain. She has a history of subfertility for 5 years and now has 2 children conceived naturally. She complains of deep dyspareunia for the last 3 months. She has undergone multiple surgeries, including a laparoscopy for an ovarian cyst and two caesarean sections. She has no desire for future fertility.

How would your history taking help you differentiate between the potential causes of her pelvic pain?

My history taking would be crucial to build a picture suggestive of endometriosis and to differentiate it from other causes of chronic pelvic pain (CPP) and dysmenorrhoea.

Key Areas of Inquiry and Their Significance:

  • Pain History (SOCRATES):
    • Timing: I would ask precisely when the pain occurs in relation to her menstrual cycle. Does it start a few days before her period and last throughout? Significance: This cyclical nature is the classic presentation of endometriosis. In contrast, primary dysmenorrhoea typically starts with the onset of bleeding and lasts 48-72 hours.
    • Character: I’d ask her to describe the pain. Significance: A heavy, “dragging” pain is typical of endometriosis or adenomyosis, while a spasmodic, colicky pain is more suggestive of primary dysmenorrhoea.
    • Associated Symptoms:
      • Deep Dyspareunia: Her complaint of deep pain during intercourse is a red flag for endometriosis, particularly involving the uterosacral ligaments or Pouch of Douglas.
      • Dyschezia: I would specifically ask if she has pain on opening her bowels, especially during her period. Significance: This is highly suggestive of rectovaginal endometriosis.
      • Bowel/Bladder Symptoms: I’d ask about cyclical bowel changes (diarrhoea, constipation) or urinary symptoms. Significance: This could indicate endometriotic involvement of the bowel or bladder.
  • Gynaecological and Surgical History:
    • Subfertility History: Her past history of subfertility is significant. Significance: Endometriosis is a well-known cause of subfertility due to adhesions and inflammation.
    • Previous Surgeries: Her history of multiple surgeries (laparoscopy, C-sections) is important. Significance: While surgery can be for endometriosis, it also increases the risk of pelvic adhesions, which are another major cause of chronic pelvic pain and deep dyspareunia.
  • Differential Diagnosis – Other Causes of CPP:
    • Adenomyosis: I would ask about heavy menstrual bleeding (HMB). Significance: The combination of HMB and worsening secondary dysmenorrhoea in a parous woman is classic for adenomyosis.
    • Pelvic Inflammatory Disease (PID): I would take a full sexual history, including past STIs. Significance: Chronic PID can cause adhesions and pelvic pain, although it is often associated with a history of purulent vaginal discharge.
Source: NICE guideline [NG73] – Endometriosis: diagnosis and management; Gynaecology by Ten Teachers, 21st Edition, Chapter 11.
What specific findings would you look for on clinical examination and what is their significance?

The aim of the examination is to elicit the specific signs of endometriosis, which are often subtle. The absence of clinical signs does not exclude the diagnosis.

Abdominal Examination:

  • Findings: I would look for tenderness, particularly in the lower abdomen, and any palpable masses.
  • Significance: Generalised tenderness is non-specific. A palpable mass could be an endometrioma (a ‘chocolate cyst’ of the ovary). Tenderness over her caesarean section scars could indicate scar endometriosis.

Pelvic Examination (with chaperone and consent):

  • Speculum Examination:
    • Finding: I would carefully inspect the posterior vaginal fornix.
    • Significance: Bluish or reddish nodules visible behind the cervix are a pathognomonic sign of vaginal endometriosis.
  • Bimanual Examination: This is the most important part of the examination.
    • Finding: I would specifically palpate the posterior fornix for tenderness and nodularity. I would assess the mobility of the uterus.
    • Significance:
      • Uterosacral ligament nodularity and tenderness: This is a classic sign of deep infiltrating endometriosis.
      • Fixed, retroverted uterus: This suggests significant adhesions have pulled the uterus backwards and fixed it in place, a condition often referred to as a “frozen pelvis.” This is a strong indicator of advanced endometriosis or adhesions from previous surgery.
      • Adnexal tenderness or mass: This could indicate the presence of an endometrioma.
Source: RCOG Patient Information Leaflet – Endometriosis; Gynaecology by Ten Teachers, 21st Edition, Chapter 11.
The examination reveals a fixed, retroverted uterus and nodularity in the posterior fornix. What is your management plan, considering she has completed her family?

The history and examination are highly suggestive of advanced, deep infiltrating endometriosis. The management should be stepwise, starting with medical therapy, but given her completed family, definitive surgical options are also very relevant.

1. Investigations to Confirm Diagnosis and Assess Extent:

  • Transvaginal Ultrasound (TVUSS): This is the first-line imaging. I would look for endometriomas and signs of deep infiltrating endometriosis, such as adhesions causing ‘kissing ovaries’.
  • Pelvic MRI: If deep infiltrating endometriosis is suspected (especially with bowel symptoms or clinical findings of nodularity), an MRI is the investigation of choice. Significance: It provides a detailed ‘roadmap’ of the disease, showing the extent of infiltration into the rectovaginal septum, bowel, or bladder, which is crucial for surgical planning.

2. Management Options (since fertility is not desired):

I would discuss a tiered approach, from medical to surgical.

  • Medical Management (to control symptoms):
    • Hormonal Suppression: The goal is to suppress the menstrual cycle and stop the endometriotic deposits from bleeding.
      • Levonorgestrel-releasing Intrauterine System (LNG-IUS): An excellent choice as it reduces both pain and bleeding with minimal systemic effects.
      • Combined Oral Contraceptive Pill (COCP): Can be taken continuously to induce amenorrhoea.
      • GnRH Analogues: These induce a reversible “medical menopause.” They are very effective for pain but are limited to 6-12 months of use due to bone density loss unless given with HRT ‘add-back’ therapy. They are often used as a pre-operative measure to shrink disease.
  • Surgical Management (Definitive Treatment):
    • Since she has completed her family and has severe symptoms, a definitive surgical approach is a very appropriate option.
    • The procedure would be a Laparoscopic Total Hysterectomy and Bilateral Salpingo-oophorectomy (BSO), with excision of all visible endometriotic deposits.
    • Significance: Removing the uterus (source of menstruation) and the ovaries (source of oestrogen) is the most effective way to treat endometriosis and prevent recurrence. This requires a detailed discussion about surgical menopause and the risks and benefits of Hormone Replacement Therapy (HRT) post-operatively. This is complex surgery, especially with a “frozen pelvis”, and should be performed by a specialist in a centre with experience in advanced laparoscopic surgery for endometriosis.
Source: NICE guideline [NG73] – Endometriosis: diagnosis and management.

Gynaecology Long Case: Ovarian/Adnexal Mass

Patient Summary – Initial Presentation

A 46-year-old previously well woman, mother of one, presents with a 3-month history of worsening lower abdominal pain, distension, and early satiety. She also reports a 6-month history of irregular menstrual bleeding, including some post-menopausal bleeding episodes. She has no fertility wishes. She recalls a previous diagnosis of a 6.5 cm right-sided ovarian cyst a year ago, which was being conservatively managed. She also has a history of dysmenorrhoea and deep dyspareunia, and has previously undergone a laparoscopy for an ovarian cyst (suspected endometrioma). Recently (3 days prior to presentation), she experienced an acute worsening of her left lower abdominal pain, accompanied by intermittent left lower back pain, nausea, vomiting, and faintishness. On examination, a 16-week sized pelvic mass is appreciated along with ascites.

How would your history taking help you differentiate between the potential causes of her pelvic pain and the nature of the ovarian mass?

My history taking would be crucial to build a picture suggestive of the underlying pathology (benign, endometrioma, or malignant) and to differentiate it from other causes of chronic pelvic pain (CPP) and acute abdominal pain.

Key Areas of Inquiry and Their Significance:

  • Pain History (SOCRATES):
    • Timing & Character: I would ask about the onset, duration, progression, and nature of the chronic abdominal pain, distension, and early satiety. Significance: Gradual onset and worsening of these symptoms, especially with early satiety, are “red flags” for ovarian malignancy. Acute, severe pain (like her recent presentation) suggests complications such as ovarian torsion, rupture, or haemorrhage into a cyst.
    • Cyclical vs. Non-cyclical: Is the pain related to her menstrual cycle? Her history of dysmenorrhoea and a previous suspected endometrioma is key. Significance: Pain worsening around menstruation, particularly severe dysmenorrhoea and deep dyspareunia, is highly suggestive of endometriosis/endometrioma. Non-cyclical pain points to other causes including malignancy or adhesions.
    • Associated Symptoms:
      • Bowel/Bladder Symptoms: I would specifically ask about cyclical dyschezia (painful bowel movements during periods), diarrhoea, constipation, or cyclical urinary symptoms. Significance: These are suggestive of deep infiltrating endometriosis affecting the bowel or bladder. Persistent or new-onset bowel habit changes can also indicate bowel malignancy or extrinsic compression by a large mass.
      • Deep Dyspareunia: Her complaint is a strong indicator of endometriosis involving the uterosacral ligaments or Pouch of Douglas, or a large fixed mass.
      • Weight loss/Loss of Appetite/Fatigue: Systemic symptoms like these are highly concerning for malignancy.
  • Menstrual History:
    • Post-menopausal Bleeding (PMB): Her reported episodes of PMB are critical. Significance: While PMB is most commonly due to endometrial pathology, it warrants full investigation as it can be associated with hormone-secreting ovarian tumours (though rare for epithelial ovarian cancer).
    • Menstrual Irregularities: Any changes in cycle length, flow, or intermenstrual bleeding.
  • Gynaecological and Surgical History:
    • Previous Ovarian Cyst Diagnosis (6.5 cm right-sided): I would inquire about its nature (simple/complex), follow-up, and any changes noted over time. Significance: A previously benign-appearing cyst can sometimes undergo malignant transformation (rare) or an initially misdiagnosed complex cyst could be progressing. Acute complications of this pre-existing cyst (torsion, rupture) would explain her acute symptoms.
    • Previous Laparoscopy for Ovarian Cyst (Endometrioma): Significance: Confirms a history of endometriosis, making recurrent endometrioma a possibility. Also, any previous abdominal surgery increases the risk of pelvic adhesions, which are a common cause of chronic pelvic pain and dyspareunia.
    • Subfertility History: Relevant for endometriosis as a cause.
  • Past Medical History:
    • Any history of breast cancer (BRCA gene link), Lynch syndrome (HNPCC), or other cancers (increases risk of ovarian cancer).
    • Any chronic liver or cardiac conditions that could cause ascites (to exclude non-gynaecological causes).
  • Family History: Specifically ask about ovarian, breast, or colorectal cancers. Significance: A strong family history can indicate a genetic predisposition (e.g., BRCA1/2, Lynch syndrome), significantly increasing the risk of ovarian malignancy.
  • Social History: Smoking, alcohol, recreational drug use, socioeconomic status (impacts compliance and access to care).
  • Drug History: Any medications that could affect symptoms (e.g., anticoagulants causing haemorrhage into a cyst).

At the end of the history, the combination of chronic “red flag” symptoms (abdominal pain, distension, early satiety) in a perimenopausal woman, with PMB, and acute worsening, along with a history of an ovarian cyst and endometriosis, strongly points towards a differential of Ovarian Malignancy (primary or metastatic) vs. a complicated (e.g., torsed/ruptured/haemorrhagic) benign ovarian cyst (including endometrioma).

Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
What specific findings would you look for on clinical examination and what is their significance?

The examination aims to assess the patient’s general health, look for signs of advanced disease, and characterise the abdominal/pelvic mass.

General Examination:

  • Vital Signs: Assess for signs of shock (tachycardia, hypotension, pallor, faintishness) indicating acute haemorrhage or torsion. Fever could suggest infection.
  • Cachexia/Weight Loss: Suggests chronic illness, highly concerning for malignancy.
  • Pallor: May indicate anaemia (chronic blood loss, malignancy).
  • Lymphadenopathy: Particularly supraclavicular (Virchow’s node) or inguinal nodes, indicating metastatic spread.
  • Jaundice: May suggest liver metastases.
  • Lower Limb Oedema: Can indicate deep vein thrombosis (DVT) associated with malignancy or lymphatic obstruction due to pelvic masses.

Abdominal Examination:

  • Inspection: Note abdominal distension, visible masses, or surgical scars.
  • Palpation:
    • Mass Assessment: Characterise the mass based on SOCRATES for a lump:
      • Site: Pelvic, arising from the pelvis.
      • Size: (e.g., 16-week size). Larger size often correlates with higher suspicion for malignancy or acute issues like torsion.
      • Shape: Regular or irregular.
      • Surface: Smooth or nodular. Significance: Nodularity is highly suspicious for malignancy.
      • Consistency: Cystic, firm, or hard. Significance: Solid or mixed solid-cystic components are more concerning for malignancy. Soft, cystic consistency is typical of benign cysts.
      • Tenderness: Generalised or localised. Significance: Generalised tenderness with guarding/rebound suggests peritonitis (e.g., from rupture). Localised tenderness, especially severe, can indicate acute torsion or haemorrhage into a cyst.
      • Mobility: Free or fixed. Significance: Fixedness suggests adhesions or invasion into surrounding structures, highly suspicious for malignancy or severe endometriosis.
    • Ascites: Assess for shifting dullness and fluid thrill. Significance: Presence of ascites, especially new-onset or significant amount, is a strong indicator of ovarian malignancy (peritoneal carcinomatosis) in this age group.
    • Organomegaly: Palpate for hepatomegaly (liver metastases) or splenomegaly.
  • Percussion: To confirm distension and delineate the mass, and assess for ascites.
  • Auscultation: Bowel sounds (may be reduced in ileus due to obstruction or peritonitis).

Pelvic Examination (with chaperone and consent):

  • Speculum Examination:
    • Inspect the cervix and vagina: For any visible lesions, discharge (rule out PID), or bluish/reddish nodules (vaginal endometriosis). In the context of PMB, inspect for cervical polyps or lesions.
  • Bimanual Examination: This is the most important part of the examination for adnexal masses.
    • Cervix: Assess consistency, mobility, and tenderness. Significance: Fixed cervix (“frozen pelvis”) suggests advanced disease with parametrial infiltration (malignancy or severe endometriosis).
    • Uterus: Assess size, position, and mobility. A fixed, retroverted uterus is a classic sign of significant adhesions or advanced endometriosis.
    • Adnexal Mass: Re-assess the mass characteristics as above (size, consistency, mobility, tenderness). Significance: A firm, nodular, irregular, or fixed adnexal mass is highly suspicious for malignancy. A unilateral, mobile, smooth, cystic mass is more likely benign. Bilateral masses raise suspicion for malignancy or bilateral endometriomas.
    • Pouch of Douglas: Palpate for nodularity or masses. Significance: Nodularity in the Pouch of Douglas or uterosacral ligaments is a classic sign of peritoneal seeding from ovarian cancer or deep infiltrating endometriosis.
  • Rectal Examination (if indicated, with consent): To assess rectovaginal septum for nodularity or infiltration, and pelvic walls for extension of the mass. Useful if bowel symptoms are prominent.
Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
How would you investigate this patient?

Investigations:

  • Full Blood Count (FBC): To check for anaemia (chronic blood loss, malignancy, or acute haemorrhage), and leukocytosis (infection, or in acute events like torsion/rupture).
  • Renal Function Tests (RFTs) & Liver Function Tests (LFTs): To assess baseline organ function, especially before surgery or chemotherapy, and to identify any metastases. Important if contrast-enhanced imaging is considered.
  • Electrolytes: Baseline, especially if vomiting due to acute pain or bowel obstruction.
  • Inflammatory Markers (CRP, ESR): May be elevated in malignancy, inflammation, or acute events like torsion/rupture.
  • Tumour Markers:
    • CA 125: This is the most widely used tumour marker for epithelial ovarian cancer. It is elevated in approximately 80% of epithelial ovarian cancers, but also in many benign conditions (e.g., endometriosis, fibroids, PID, liver disease, pregnancy, acute torsion/rupture). Its primary use is in risk assessment and monitoring.
    • Other markers (if indicated): AFP, HCG (germ cell tumours), LDH (dysgerminoma), Inhibin (granulosa cell tumours).
    • HE4 (Human Epididymis Protein 4): Can be used with CA125 to calculate the ROMA (Risk of Ovarian Malignancy Algorithm) score, which can improve differentiation between benign and malignant pelvic masses, especially in pre- and post-menopausal women.
  • Imaging:
    • Transvaginal Ultrasound (TVUS) with Doppler: This is the first-line imaging for characterising an ovarian mass. It provides detailed information on morphology and blood flow, crucial for evaluating acute complications like torsion.
    • Pelvic MRI: If TVUS is inconclusive or to better delineate the extent of a mass, particularly for deep infiltration, or complex anatomy. It is excellent for assessing solid components, septations, and invasion of adjacent organs.
    • CT Scan (Chest, Abdomen, and Pelvis): Essential for staging if malignancy is suspected. It helps assess the extent of disease, presence of ascites, peritoneal deposits, lymphadenopathy, and distant metastases (e.g., liver, lung). It is crucial for surgical planning. For acute presentations, it can also help identify complications like rupture or peritonitis.
  • ECG & Echo (if indicated): For pre-operative assessment of cardiac fitness, especially for major surgery or if patient has co-morbidities.
  • Endometrial Biopsy/Hysteroscopy with Biopsy: Given the history of post-menopausal bleeding, this is crucial to exclude endometrial malignancy, as it is a common cause of PMB.
Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
How do you differentiate between malignant and benign ovarian masses based on ultrasound findings?

Ultrasound features are assessed using scoring systems like the IOTA (International Ovarian Tumour Analysis) criteria or the Risk of Malignancy Index (RMI). Key features suggestive of malignancy include:

Feature Benign Features (Suggestive of) Malignant Features (Suggestive of)
Size Usually < 10 cm Typically > 10 cm (though small cancers exist)
Morphology Unilocular cyst (simple cyst), smooth walls Multilocular cyst, solid components (papillary projections), thick septations (>3 mm)
Internal Content Anechoic fluid (clear), fine internal echoes (haemorrhagic cyst) Solid areas, echogenic fluid (ascites)
Vascularity (Doppler) Absent or minimal flow in cyst wall, normal flow in ovarian stroma Presence of solid components with high vascularity (low resistance flow, high peak systolic velocity) within the mass. In acute torsion, lack of Doppler flow within the ovary is a key sign.
Ascites Absent or minimal (e.g., physiological) Presence of ascites (especially significant amount, in post-menopausal women)
Peritoneal Deposits Absent Presence of peritoneal deposits or omental cake
Bilateral Involvement Less common More common

The Risk of Malignancy Index (RMI) combines menopausal status, ultrasound score, and CA125 level to stratify risk. RMI 1-3 are commonly used, with RMI >200-250 highly suggestive of malignancy, warranting referral to a gynaecological oncology centre.

Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
What would be your next steps if malignancy is highly suspected (e.g., CA 125 is 400 and other features)?

Given a high CA 125 level (e.g., 400 U/mL) and other concerning symptoms and findings, the next steps are:

  • Multidisciplinary Team (MDT) Discussion: The case must be discussed in a gynaecological oncology MDT meeting involving gynaecological oncologists, radiologists, pathologists, and oncologists. This ensures a comprehensive approach to diagnosis and treatment planning.
  • Further Imaging (CT Chest, Abdomen, Pelvis): To accurately stage the disease and identify any distant metastases or extent of peritoneal spread. This is crucial for surgical planning and determining resectability.
  • Referral to Gynaecological Oncology Centre: Management of suspected ovarian cancer should be carried out in a specialised centre with expertise in gynaecological oncology.
  • Counselling the Patient: Discuss the suspected diagnosis, the need for further investigations, treatment options (surgery, chemotherapy), and potential prognosis. Address concerns regarding body image, sexuality, and quality of life.
  • Nutritional and Psychological Support: Patients with advanced ovarian cancer often have poor nutritional status and require significant emotional support.
  • Preparation for Staging Laparotomy / Debulking Surgery: If the patient is deemed fit for surgery and the disease is considered resectable, the primary treatment is usually surgical debulking. This involves a laparotomy to remove as much of the tumour as possible, including the primary ovarian tumour, uterus, fallopian tubes, omentum, and any visible peritoneal deposits. This is followed by histopathological confirmation of the diagnosis and staging.
  • Consider Neoadjuvant Chemotherapy: In cases of extensive disease or if the patient’s general condition is poor, neoadjuvant chemotherapy may be given before surgery to shrink the tumour and improve surgical outcomes.
Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
If this was a benign ovarian mass, what would be your management, considering the patient’s age (46) and no fertility wishes (according to the latest guidelines)?

If the ovarian mass is definitively diagnosed as benign (either pre-operatively based on imaging and tumour markers, or post-operatively after initial surgery for presumed benignity), the management approach would be different from malignancy, focusing on symptom relief and preventing recurrence, while considering her age and completed family. The acute presentation (nausea, vomiting, faintishness) suggests a complication like torsion or rupture, which would usually prompt urgent surgical intervention regardless of benignity.

Management Options for Benign Ovarian Mass (Patient aged 46, no fertility wishes):

The choice of management depends on the type of benign cyst, symptoms, size, and patient’s preference. Given her age, chronic symptoms, acute exacerbation, and no fertility wishes, surgical options are generally preferred over conservative management for symptomatic cysts.

  • Conservative Management (Watchful Waiting):
    • For small, asymptomatic, simple (unilocular, anechoic) cysts, especially if malignancy is confidently excluded, conservative management with repeat ultrasound surveillance (e.g., in 3-6 months) can be considered. Many simple cysts resolve spontaneously.
    • However, given her acute symptoms, chronic symptoms (pain, distension), and the size of the cyst (6.5 cm previously, and now a 16-week sized mass), this would unlikely be the primary approach. It might be considered only if acute torsion/rupture is ruled out, the mass is confirmed simple, and symptoms resolve.
  • Surgical Management: This is generally preferred for symptomatic benign cysts, cysts with concerning features (even if benign), or larger cysts, and certainly for acute complications like torsion or rupture. The approach can be either laparoscopic or via laparotomy, depending on size, complexity, and suspicion of malignancy.
    • Ovarian Cystectomy:
      • Procedure: This involves removing only the cyst while preserving the ovarian tissue.
      • Indication: It is typically performed for younger women who wish to preserve fertility. For a 46-year-old with no fertility wishes, it is an option, especially for a unilateral cyst, if the remaining ovarian tissue is healthy and preserving ovarian function is beneficial (e.g., to avoid surgical menopause or continue natural hormone production). This is also the procedure for detorsion of a viable ovary.
      • Benefits: Preserves ovarian function, avoiding surgical menopause.
      • Risks: Risk of cyst recurrence, risk of damage to the remaining ovarian tissue.
    • Oophorectomy (Salpingo-Oophorectomy):
      • Procedure: This involves removing the entire affected ovary (and usually the fallopian tube on that side).
      • Indication: This is a very appropriate and often preferred option for a 46-year-old with a symptomatic benign ovarian mass who has completed her family. It removes the source of the problem, eliminates the risk of recurrence in that ovary, and removes the future risk of ovarian cancer in that ovary. For acute torsion, if the ovary is necrotic, oophorectomy is indicated.
      • Unilateral Salpingo-Oophorectomy (USO): If the cyst is unilateral and the other ovary appears normal.
      • Bilateral Salpingo-Oophorectomy (BSO): If both ovaries are affected by benign masses, or if there is a strong family history of ovarian cancer (e.g., BRCA mutation carriers), or if the patient is peri-menopausal and approaching menopause. This would induce surgical menopause, necessitating discussion about Hormone Replacement Therapy (HRT).
      • Benefits: Definitive treatment, no risk of recurrence in the removed ovary, eliminates future ovarian cancer risk in the removed ovary.
    • Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAH+BSO):
      • Indication: This more extensive surgery would be considered if there are co-existing uterine pathologies (e.g., significant fibroids, adenomyosis causing heavy bleeding or pain), or if the patient requests it for complete cessation of menstrual periods and removal of all gynaecological cancer risk. Given her age and chronic symptoms, this might be a comprehensive solution if other benign pathologies are present.
      • Benefits: Comprehensive solution to multiple gynaecological issues.
      • Considerations: Induces surgical menopause, requires HRT discussion.
  • Laparoscopic vs. Laparotomy: The vast majority of benign ovarian cysts can be managed laparoscopically, which offers faster recovery, less pain, and smaller scars. Laparotomy may be necessary for very large cysts, if malignancy is still suspected despite pre-operative assessment (to allow for full staging), or in cases of significant adhesions. For acute conditions like torsion or rupture, laparoscopy is usually the first choice for diagnosis and intervention.

Latest Guidelines (RCOG & NICE):

Both RCOG and NICE guidelines advocate for an individualised approach based on risk assessment (e.g., RMI score, ultrasound features), patient’s symptoms, age, and fertility wishes. For symptomatic benign ovarian cysts in women nearing menopause or post-menopausal, oophorectomy is generally a recommended and definitive treatment. Conservative management is an option for small, simple, asymptomatic cysts. The surgical approach (laparoscopy vs. laparotomy) depends on the size, complexity, and clinical suspicion of malignancy. For the 6.5 cm cyst with acute symptoms, an urgent surgical assessment is warranted to rule out torsion or rupture, which would likely lead to laparoscopic management (detorsion/cystectomy/oophorectomy).

Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.

Patient Summary – Post-operative Complication

Following further investigations, the patient’s transvaginal ultrasound (TVUS) showed a 6.5 cm right-sided unilocular ovarian cyst with fine internal echoes, and her CA 125 level was 30 U/mL. Given her persistent symptoms and the acute exacerbation, she underwent an uncomplicated laparoscopic right ovarian cystectomy under general anaesthesia. However, on post-operative day one, she developed significant lower abdominal pain, which was more severe than expected post-operatively.

What are the potential causes of this patient’s post-operative abdominal pain?

Post-operative abdominal pain on day 1 is common but requires careful evaluation to differentiate expected post-surgical discomfort from complications. After laparoscopic cystectomy, the causes can range from benign to life-threatening.

Potential Causes of Post-Operative Abdominal Pain (Day 1):

  1. Expected Post-operative Pain:
    • Incision site pain: From the laparoscopic port sites.
    • Gas pain: Due to residual carbon dioxide in the abdominal cavity from insufflation during laparoscopy, often referred to to the shoulder (diaphragmatic irritation).
    • Visceral pain: From manipulation of organs during surgery, particularly the bowel.
  2. Surgical Complications:
    • Bowel Perforation/Injury: This is a serious, albeit rare, complication of laparoscopic surgery. It can lead to peritonitis and severe pain.
    • Haemorrhage/Haematoma: Bleeding from the surgical site (e.g., ovarian bed, port sites) or damage to a blood vessel. Can cause pain, distension, and signs of hypovolaemia.
    • Urinary Tract Injury (Bladder or Ureter): Can cause lower abdominal or flank pain. Leakage of urine into the peritoneal cavity can cause peritonitis.
    • Infection: Wound infection, pelvic infection, or peritonitis. Less common on Day 1 unless contamination occurred intra-operatively.
    • Adhesive Small Bowel Obstruction: Unlikely on Day 1 unless pre-existing adhesions were significantly manipulated or injured.
    • Ovarian Remnant Syndrome/Residual Endometriosis: If the cystectomy was for endometriosis and some endometriotic tissue was left behind, it could cause ongoing pain, but typically not acute pain on Day 1.
  3. Other Medical Conditions:
    • Urinary Retention: Common post-operatively due to anaesthesia or pain, causing suprapubic pain.
    • Deep Vein Thrombosis (DVT): While not abdominal pain, it’s a post-op complication to be mindful of.
Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
How would you manage this patient’s post-operative abdominal pain?

My approach would be systematic to rule out serious complications first, while managing expected pain.

  1. Immediate Clinical Re-assessment:
    • Full History: Characterise the pain (onset, severity, type, radiation), associated symptoms (nausea, vomiting, fever, chills, bowel changes, urinary symptoms, dizziness, faintishness). Ask about last bowel movement and flatus.
    • Full General Examination:
      • Vital Signs: Look for fever, tachycardia, hypotension (suggesting sepsis or haemorrhage).
      • Abdominal Examination: Look for distension, tenderness (localised vs. generalised, rebound, guarding, rigidity), bowel sounds (absent or tinkling), palpable masses.
      • Per Rectal Examination (if indicated): To assess for pelvic tenderness or masses.
  2. Initial Investigations (STAT):
    • Full Blood Count (FBC): To check for leukocytosis (infection) or significant drop in haemoglobin (haemorrhage).
    • Inflammatory Markers (CRP): Will be elevated post-op, but a significant and rapid rise can suggest infection/inflammation.
    • Electrolytes & Renal Function Tests: To assess hydration and kidney function, especially if vomiting.
    • Urinalysis: To rule out urinary tract infection.
    • Serum Lactate: If suspicion of bowel ischaemia or sepsis is high.
  3. Imaging:
    • Erect Abdominal X-ray: What to look for: Free gas under the diaphragm (pneumoperitoneum), which is highly suggestive of a bowel perforation. Small amounts of free gas can be present normally after laparoscopy for 24-48 hours, but a large amount, or increasing amount, is pathological. Other findings: Dilated bowel loops, air-fluid levels (suggesting obstruction).
    • Abdominal Ultrasound: Can identify collections (haematoma, abscess), fluid (ascites), or urinary tract dilation (hydronephrosis from ureteric injury).
    • CT Abdomen and Pelvis with IV contrast (if stable): This is the most definitive imaging modality if a serious intra-abdominal complication (e.g., bowel injury, major bleeding, abscess) is suspected. It provides detailed anatomical information. Oral contrast may be given to look for bowel leaks.
  4. Other Investigations:
    • Vaginal/Cervical Swabs: If there’s any purulent discharge suggesting infection.
    • Fluid Culture: If any collections are drained.

The immediate priority is to rule out life-threatening complications like bowel perforation or significant haemorrhage. If a bowel perforation or other severe complication is suspected, urgent surgical exploration (laparotomy or re-laparoscopy) would be indicated.

Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
“`
“`html

Gynaecology Long Case: Hydatidiform Mole

Patient Summary

A 32-year-old woman presents for suction evacuation of a hydatidiform mole at 12 weeks of amenorrhoea. She was diagnosed with a hydatidiform mole at her first dating scan at 9 weeks POA. She reports one episode of per vaginal bleeding (PVB) without passage of vesicles or clots. She also complains of vomiting for the past two weeks. Her last menstrual period (LMP) is unsure, but her symphysio-fundal height (SFH) is noted to be 20 weeks. No other significant symptoms were reported.

What are your differential diagnoses for this patient’s presentation, and how would you exclude them in your history taking?

Given the patient’s presentation with per vaginal bleeding, vomiting, and a symphysio-fundal height (SFH) significantly larger than her stated period of amenorrhoea (POA), my primary differential diagnosis is a Hydatidiform Mole (Molar Pregnancy). However, other conditions must be considered and actively excluded.

Differential Diagnoses and Historical Exclusion:

  1. Threatened/Inevitable/Incomplete Miscarriage:
    • Exclusion in History: I would ask about passage of fetal tissue or products of conception. While PVB is common, the discrepancy between SFH and POA (20 weeks vs 12 weeks) and significant vomiting make miscarriage less likely as a primary diagnosis for this presentation. However, a missed or incomplete miscarriage with gestational trophoblastic disease (GTD) changes could be a consideration, but the “snow storm” appearance on USS would largely rule out a simple miscarriage.
  2. Multiple Pregnancy (e.g., Twins):
    • Exclusion in History: I would ask if there is a family history of multiple pregnancies.
    • Exclusion by Investigations: This is primarily excluded by ultrasound. [cite_start]While multiple pregnancies can cause SFH greater than dates and increased hCG (leading to more severe nausea/vomiting), the ultrasound features of a molar pregnancy are distinct from a viable multiple gestation[cite: 1].
  3. Gestational Age Miscalculation (Wrong Dates):
    • Exclusion in History: Her unsure LMP supports this possibility. I would try to clarify her LMP further, ascertain the regularity of her cycles, and ask about the date of conception if known (e.g., IVF).
      • [cite_start]
    • Exclusion by Investigations: This is mainly excluded by the definitive ultrasound findings (snowstorm appearance) and extremely high hCG levels, which are not typical for a normal singleton or even multiple pregnancy of 12 weeks[cite: 1].
  4. Large for Dates Uterus due to other causes:
    • Uterine Fibroids: Could cause uterine enlargement. Exclusion: Would ask about previous diagnosis of fibroids, heavy menstrual bleeding (HMB), or pressure symptoms. Ultrasound would differentiate.
    • Polyhydramnios: Excess amniotic fluid. Exclusion: Ultrasound would clearly differentiate between polyhydramnios and a molar pregnancy.
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
What pregnancy symptoms are suggestive of a hydatidiform mole, and what are the differences between nausea, vomiting, and hyperemesis gravidarum?

Pregnancy Symptoms Suggestive of Hydatidiform Mole:

While definitive diagnosis is by ultrasound and hCG levels, certain clinical features raise suspicion for a hydatidiform mole:

  • Per Vaginal Bleeding (PVB): This is the most common symptom, occurring in almost all cases. It can range from spotting to heavy haemorrhage. [cite_start]While the patient reported one episode without vesicles or clots, passage of grape-like vesicles is pathognomonic but less common now with earlier diagnosis[cite: 1].
  • Uterus Larger than Dates: Symphysio-fundal height (SFH) is significantly larger than expected for gestational age, as seen in this patient (SFH 20 weeks at 12 weeks POA). [cite_start]This occurs due to the rapid proliferation of trophoblastic tissue and/or accumulation of blood and fluid within the uterus[cite: 1].
  • Excessive Nausea and Vomiting/Hyperemesis Gravidarum: Due to abnormally high levels of beta-human chorionic gonadotropin (beta-hCG), which are much higher in molar pregnancies than in normal gestation. The patient reported vomiting for two weeks.
  • Early Onset of Pre-eclampsia/Eclampsia: Development of hypertension, proteinuria, and oedema before 20 weeks of gestation (rare in normal pregnancy).
  • Absent Fetal Heart Sounds (FHS) or Fetal Parts (on palpation): This is expected in complete moles as there is no fetus.
  • Theca-Lutein Cysts: Bilateral ovarian cysts may be palpable on examination or seen on ultrasound, caused by excessive hCG stimulation of the ovaries.
  • Hyperthyroidism Symptoms: Palpitations, tremors, heat intolerance, weight loss despite increased appetite, due to hCG stimulating thyroid receptors.

Difference between Nausea, Vomiting, and Hyperemesis Gravidarum:

  • Nausea: A subjective unpleasant sensation of needing to vomit. It is very common in early pregnancy (morning sickness).
  • Vomiting: The forceful expulsion of stomach contents through the mouth. It can occur with or without nausea. While common in early pregnancy, persistent vomiting should be assessed. The patient reported vomiting for two weeks.
  • Hyperemesis Gravidarum (HG): A severe form of nausea and vomiting in pregnancy, characterised by:
    • Persistent, excessive vomiting.
    • Dehydration (evidenced by clinical signs).
    • Electrolyte imbalance (e.g., hypokalemia).
    • Weight loss (typically >5% of pre-pregnancy weight).
    • This is a clinical diagnosis requiring medical intervention beyond simple antiemetics and dietary advice. It is a more severe and pathological entity than typical pregnancy-related nausea and vomiting.
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
What are you expecting to find on abdominal examination, and how would you perform it?

Before performing the abdominal examination, based on her symptoms and history (SFH 20 weeks at 12 weeks POA, PVB, vomiting), I would strongly expect findings consistent with an enlarged uterus and potentially associated masses.

Expected Findings on Abdominal Examination:

  • Enlarged Uterus: The symphysio-fundal height (SFH) is expected to be significantly larger than the gestational age calculated from LMP/dating scan (e.g., 20 weeks SFH at 12 weeks POA in this case). [cite_start]This is a hallmark sign of molar pregnancy[cite: 1].
  • Soft, Doughy Consistency of Uterus: The uterus may feel less firm than a normal gravid uterus.
    • [cite_start]
  • Absent Fetal Parts/Fetal Heart Sounds: In a complete mole, no fetal parts will be palpable, and no fetal heart sounds will be audible[cite: 1]. This is a crucial negative finding.
  • Pelvic/Adnexal Masses: If large theca-lutein cysts are present, they might be palpable as bilateral, soft, cystic masses in the adnexa.

How to Perform Abdominal Examination:

  1. Preparation: Ensure patient comfort and privacy. Ask her to empty her bladder. Explain the procedure and obtain consent.
  2. Inspection: Observe for abdominal distension, scars, striae gravidarum.
  3. Palpation (Leopold’s Manoeuvres):
    • First Maneuver (Fundal Grip): Determine the height of the fundus (Symphysio-Fundal Height) and its consistency. Note if it feels unusually large for dates or has a soft/doughy feel.
    • Second Maneuver (Lateral Grip): Palpate the sides of the uterus to identify fetal limbs or the fetal back. [cite_start]In a molar pregnancy, these will be absent[cite: 1]. Assess for any palpable adnexal masses (theca-lutein cysts).
    • Third Maneuver (Pawlik’s Grip/Pelvic Grip for lower pole): Palpate the lower pole of the uterus to determine the presenting part. In a molar pregnancy, no fetal pole will be felt.
    • Fourth Maneuver (Pelvic Grip for engagement): If a head is suspected, assess its engagement (not applicable here).
  4. Auscultation: Attempt to auscultate fetal heart sounds (FHS) using a Pinard stethoscope or Doppler. [cite_start]In a complete mole, FHS will be absent[cite: 1].
  5. Percussion: Over the fundus to confirm uterine borders.
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
What investigations would you perform for this patient?

The investigations are crucial for confirming the diagnosis of hydatidiform mole, assessing its extent, and preparing the patient for evacuation.

Investigations:

  1. Quantitative Serum Beta-hCG Levels:
      [cite_start]
    • Significance: Levels are typically abnormally high (>100,000 mIU/mL) for gestational age in molar pregnancies[cite: 1]. Serial measurements post-evacuation are essential for follow-up.
  2. Transvaginal Ultrasound (TVUS):
    • Significance: This is the diagnostic cornerstone. [cite_start]Classic findings for a complete mole include a “snowstorm” or “bunch of grapes” appearance within the uterine cavity, absence of a fetal pole or embryo, and absence of an amniotic sac[cite: 1]. Theca-lutein cysts may also be seen bilaterally in the ovaries. For a partial mole, there may be a fetus with growth restriction, polyhydramnios, and an abnormal placenta.
  3. Pre-Operative Investigations:
    • Full Blood Count (FBC): To assess for anaemia (due to PVB) and baseline haemoglobin.
    • Renel Function Tests (RFTs) & Liver Function Tests (LFTs): To assess baseline organ function, especially important before general anaesthesia and to rule out complications like pre-eclampsia or hyperthyroidism affecting these organs.
    • Blood Grouping and Cross-matching/Screening: Essential in case of significant haemorrhage during evacuation.
    • Thyroid Function Tests (TFTs): Due to the potential for hCG-induced hyperthyroidism.
    • Coagulation Profile (PT/APTT): If there is suspicion of disseminated intravascular coagulation (DIC) in severe cases, though less likely in a 12-week presentation.
    • Chest X-ray: To rule out trophoblastic embolisation or metastatic disease to the lungs (especially if there are respiratory symptoms or very high hCG). This is usually performed after initial evacuation if there’s suspicion for GTN.
    • ECG: For pre-operative assessment of cardiac fitness, especially if there are signs of hyperthyroidism or for general anaesthesia.
Source: Gyn – past viva questions – 29th _240819_175604.pdf.
Discuss the surgical management of hydatidiform mole, including expected complications, precautions, and appropriate surgical expertise.

Surgical Management:

The primary treatment for hydatidiform mole is evacuation of the uterine contents. [cite_start]For a 12-week pregnancy, suction evacuation (vacuum aspiration) is the preferred method[cite: 1].

  • Procedure: Performed under general anaesthesia. The cervix is dilated, and a suction cannula is inserted into the uterus to aspirate the molar tissue. This is often followed by gentle curettage to ensure complete removal of all tissue.
  • Hysterotomy/Hysterectomy: Hysterotomy is rarely indicated now. Hysterectomy is an option for older patients (e.g., >40 years) with completed family who desire definitive management and wish to avoid subsequent follow-up for gestational trophoblastic neoplasia (GTN), but it does not remove the risk of GTN from extrauterine sites.

Expected Complications during Surgery (Evacuation):

[cite_start]

The most commonly expected complication during suction evacuation of a hydatidiform mole is bleeding[cite: 1].

  • Haemorrhage: Molar tissue is highly vascular. [cite_start]Bleeding can be profuse and life-threatening[cite: 1].
  • Uterine Perforation: Risk of perforating the uterine wall with instruments.
  • Infection: Post-operative endometritis.
  • Fluid Overload: If large amounts of intravenous fluids are used during evacuation.
  • Amniotic Fluid Embolism/Trophoblastic Embolism: Rare but serious complication where trophoblastic cells enter the maternal circulation, leading to cardiorespiratory collapse.

Precautions for Surgery:

    [cite_start]
  • Pre-operative Assessment: Ensure patient is haemodynamically stable and all pre-op investigations are complete (FBC, blood group & cross-match, RFTs, LFTs, TFTs)[cite: 1].
  • Intravenous Access: Secure at least two large-bore IV cannulae for rapid fluid and blood product administration.
  • Blood Availability: Ensure adequate blood products (packed red cells, fresh frozen plasma) are available and cross-matched in the theatre.
  • Uterotonic Agents: Oxytocin infusion should be prepared and started immediately after evacuation to encourage uterine contraction and reduce bleeding.
  • Experienced Anaesthetist: To manage potential haemodynamic instability.
  • Surgical Technique: Gentle and systematic suction evacuation, avoiding excessive curettage.

Appropriate Surgical Expertise:

[cite_start]

Given the potential for significant haemorrhage and other complications, the evacuation of a hydatidiform mole should ideally be performed by an experienced consultant or a senior registrar (SR) who is competent in managing such cases and their potential complications[cite: 1]. This ensures timely and effective management of any adverse events.

Source: Gyn – past viva questions – 29th _240819_175604.pdf.
Describe the post-evacuation follow-up plan for a patient with a complete molar pregnancy, and what contraceptive method would you recommend?
[cite_start]

The follow-up after evacuation of a hydatidiform mole, especially a complete mole, is crucial to detect and manage Gestational Trophoblastic Neoplasia (GTN), which can develop in up to 15-20% of complete moles[cite: 1].

Post-Evacuation Follow-up Plan:

The cornerstone of follow-up is serial quantitative serum beta-hCG measurements.

  1. Weekly hCG Monitoring:
      [cite_start]
    • Measure serum beta-hCG weekly until levels are normal (<5 mIU/mL) for 3 consecutive weeks[cite: 1].
  2. Monthly hCG Monitoring:
      [cite_start]
    • Once hCG levels are normal, continue monthly monitoring for at least 6 months (for complete mole) or 3 months (for partial mole)[cite: 1].
    • The duration of follow-up can vary by national guidelines (e.g., UK guidance suggests 6 months for complete mole, 3 months for partial mole, from normalisation).
  3. Clinical Assessment: Regular clinical review to check for persistent PVB, symptoms of metastases (e.g., persistent cough for lung mets, neurological symptoms for brain mets), or uterine enlargement.
    4. [cite_start]
  4. Imaging: Chest X-ray if hCG levels plateau or rise, or if there are any respiratory symptoms, to check for pulmonary metastases[cite: 1]. Other imaging (e.g., CT/MRI) if GTN is suspected at other sites.
  5. Counselling: Provide clear counselling about the importance of strict follow-up and the need for reliable contraception.

Contraceptive Method Recommendation for Complete Molar Pregnancy:

[cite_start]

For a complete molar pregnancy, a highly effective and reliable contraceptive method is essential to prevent a new pregnancy during the follow-up period[cite: 1]. A new pregnancy would cause hCG levels to rise, making it impossible to differentiate between a new pregnancy and persistent GTN. The recommended duration of contraception is typically until the end of the follow-up period (e.g., 6-12 months after hCG normalisation for complete moles).

Recommended Method:

  • Combined Hormonal Contraceptives (Oral Contraceptive Pills, Patch, Ring): These are generally considered safe and effective. [cite_start]They do not interfere with hCG regression or increase the risk of GTN[cite: 1].
  • Progestogen-Only Methods (Pills, Injectables, Implants): Also considered safe and highly effective.
  • Intrauterine Devices (IUDs): Copper IUDs or Levonorgestrel-releasing IUDs (LNG-IUS) are generally avoided immediately after evacuation due to the theoretical risk of uterine perforation or infection in the still-healing uterus. However, they can be considered after the first negative hCG result, if the uterus is well-involuted and there are no signs of infection or complications.

The choice should be made after discussing the patient’s preferences, contraindications, and adherence capabilities, emphasizing methods with high efficacy.

Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
Which type of hydatidiform mole carries a higher risk for future molar pregnancy or gestational trophoblastic neoplasia (GTN): complete or partial hydatidiform mole?
[cite_start]

Complete hydatidiform mole carries a significantly higher risk for future gestational trophoblastic neoplasia (GTN) and a higher risk of recurrence of molar pregnancy compared to a partial hydatidiform mole[cite: 1].

  • Complete Hydatidiform Mole:
      [cite_start]
    • Risk of developing GTN: Approximately 15-20%[cite: 1].
    • Risk of recurrence of another molar pregnancy: Approximately 1% in subsequent pregnancies.
  • Partial Hydatidiform Mole:
      [cite_start]
    • Risk of developing GTN: Much lower, approximately 0.5-5%[cite: 1].
    • Risk of recurrence: Also very low.

This difference in risk is why the follow-up protocol with serial hCG measurements is more prolonged and stringent for complete moles compared to partial moles.

Source: [1] Gyn – past viva questions – 29th _240819_175604.pdf.
“`

isira

Leave a Reply

Latest Posts