27 ABSITE 2024 OBGYN- edited

Welcome back to Ab Sight Review. Today we are going to talk OBGYN. I'm Patrick here with Kevin. You ready to let it rip? Let's do it. Let's go. So what are the major ligaments of the female reproductive organs? Yeah. So you have your broad ligament, your round ligament, and your suspensory ligament. The broad ligament extends from the lateral uterus to the pelvic sidewalls, and this contains the uterine artery and vein.

Your round ligament extends from the superior lateral uterus through the inguinal canal to the labia majora. And your suspensory ligament extends from the ovary superiorly and laterally to the pelvic sidewall. This contains the ovarian artery and vein. Great. So there are certain physiologic changes that occur with pregnancy.

Kevin, what changes occur to the cardiovascular system? Yeah. So you get a physiological dilutional anemia. You get a leukocytosis, you get a thrombocytosis, you get increased fiber, fibrinogen and clotting factors. 7, 8, 9, 10. Okay. What about the

respiratory system? So you get increased tidal volume with decreased functional residual capacity and O2 consumption.

And this is a chronic compensated respiratory alkalosis. Yeah. That's something that I've actually seen on the exam before. The chronic compensated respiratory alkalosis for the pregnant patient trust, especially in the trauma setting is when this may show up as an abnormality, but it can be explained by the patient's pregnancy.

How about the GI tract? So you get decreased motility, you get decreased esophageal sphincter competency, and you get increased aspiration risk. That's right important increased aspiration risk. What is the leading cause of pregnancy related mortality in the first trimester? That's ectopic pregnancy.

Yeah, and what are the risk factors for ectopic pregnancy? So, history of pelvic inflammatory disease, or prior ectopic pregnancy, or prior tubal surgery. Increased age and smoking. Yeah. And if IUDs fail to prevent a pregnancy, the patient is at higher risk of ectopic pregnancy if they get pregnant with an IUDN.

Kevin,

what labs should be obtained for a patient that you're evaluating if you're concerned about an ectopic pregnancy? Yeah, of course you need to confirm there's a pregnancy with a beta HEG and you also need to know the RH status. Yeah, so this is like the trauma world. So if mom is RH negative, You want to give that anti RHOGAM within 72 hours of a patient presenting with presumed ruptured ectopic pregnancy.

What's the best imaging modality to evaluate? Yeah, a transvaginal ultrasound. Okay. What are the signs and symptoms concerning for rupture in patients that are presenting? So if they have severe abdominal or pelvic pain or visible peritoneal fluid. Okay. How are ectopic pregnancies managed? Right, it can be a non operative approach or an operative approach.

Yeah, many of these can be managed non operatively if the patient is hemodynamically normal, their beta HDG is less than 5000, and there's no fetal cardiac activity. In this patient, you can do methotrexate, and then you can follow up the beta HDG monitoring until it's undetectable. This is contraindicated if

the patient is hemodynamically abnormal, or has simultaneous intrauterine pregnancies, has active pulmonary disease, renal insufficiency, peptic ulcer disease, immunosuppression, or is actively breastfeeding.

Okay. Methotrexate. Methotrexate. For medical management. Okay. What about operative management? So this, you can do your salpingostomy considered for patients who desire future childbearing if the contralateral tube is damaged or absent. So you make an incision in the fallopian tube to remove the ectopic gestation.

This leaves the tube intact. Now, the other option is a salpingectomy. This is considered for patients with rupture. Tubal damage or uncontrolled bleeding, or if the gestation is greater than three to five centimeters, it's too large for a cell pingostomy. Okay, cell pingostomy is when you pull out the ectopic and preserve the tube.

Cell pingostomy is when everything is removed. Alright, let's talk CT scans in the pregnant patient. This certainly makes me sweat. Kevin, what are the risks of CT to a pregnant patient and their fetus? Yeah, so a CT abdomen

pelvis exposes the fetus to an average of 2. 5 rads. So fetal exposure less than five rads has not been associated with pregnancy loss or increased risk of congenital anomalies and The organ development is typically complete by 20 weeks Right, so pregnancy should not impede the use of necessary imaging studies for critical diagnoses What's good for the mother is good for the child.

Okay, this is most likely show up in a trauma scenario If you would normally image a patient who comes in with whatever set of injuries they present with, then if that patient's pregnant, you should probably be imaging them as well. So, on the exam, if you would normally image that patient and they happen to be pregnant, still image that patient.

All right. What about risks of anesthesia during pregnancy? This is also a high yield question. You know, you're going to be taking a patient for a general surgical procedure. They're pregnant and you need to know those risk factors. Yeah. So the ACOG recommend that elective procedures should be postponed till after the delivery, but medically necessary surgery should be

performed.

Right. And no currently used anesthesia agents are associated with teratogenicity, which is important to know, and that there's no evidence that in utero exposure to anesthesia impacts fetal brain development. All of this. Has been suggested in some animal data when they have prolonged exposure, so something that's a bit more nuanced and there is an elevated risk for preterm delivery in some procedures.

And this should definitely be considered during that perioperative period and should be discussed with patients, especially for abdominal surgery. So, during which trimesters Kevin, can laparoscopic surgery be safely performed? Yeah, I think this is kind of a change in thought over the past 10 years or so, but.

So all trimesters, if a laparoscopic procedure is technically appropriate and the patient is otherwise appropriate to tolerate laparoscopy, there's no trimester restriction. Right. And how about fetal monitoring and support, you know, in that perioperative period and intraoperatively? What's the age cutoff for viability?

Because that really informs this.

Yeah. So the viability cutoff is typically 24 weeks. So before this, you just confirm the fetal heartbeat before and after the procedure. Okay. So before and after surgery confirming your confirming your fetal heartbeat. But what about the fetus? It's more than 24 weeks of age.

So this you do continuous interoperative monitoring with external fetal heart monitor plus or minus a transvaginal ultrasound. Okay, Kevin, you're taking a pregnant patient to the operating room for laparoscopic surgery. How are you gaining access to the abdomen and getting your pneumoperitoneum? Yeah.

So generally you want to do the Hassan technique where you do the direct entry. You're not doing any blind entries. And then the positioning you need to account for the gravid uterus. So you have to sort of see what trimester they're at. So the first trimester, you can generally use normal port placement.

Once they're at 20 weeks, the uterus is at the level of the umbilicus. So you need to be, you know, super umbilical trocar. And then greater than 20 weeks, you just have to plan. It's, the uterus is gonna go one centimeter cephalad per week. Right, so you have to be very thoughtful about port

placement in those later trimester, in that third trimester.

So what are the most common non obstetric indications for surgery in pregnant patients? Happen to be the same as Yep. So Non pregnant patients do. Appendicitis is very common and then also cholecystitis. All right, let's talk trauma. There are a few truths here when it comes to pregnant patients.

First and foremost, what's good for mom is good for baby. So you want to proceed with your normal primary and secondary survey with adjuncts, including CT scan as indicated for that situation. Remember that the fetus is considered viable at 24 weeks. And on your physical exam you can take a look and find out where the top of the gravid uterus is.

If it's at the umbilicus or umbilicus, you are at 20 weeks. All right, so that can help kind of, determine how far along mom is. In a hemodynamically unstable trauma patient, you can consider tilting the patient to the left to offload the IBC and increase venous return to the heart. When

a pregnant patient arrives in the trauma bay, we will also want to assess the fetus and to do so we would perform a fetal heart monitoring in addition to an ultrasound of the fetus.

Normal heart rate for a fetus is 110 to 160 beats per minute. We also perform standard labs in our trauma patients and if the patient or the mom is RH negative, at that point we want to consider giving a RhoGAM in the setting of possible allele immunization. Remember, even a tiny bit of blood fetal blood that crosses into maternal circulation can cause this.

This is followed up with the Kleinheimer Betke test, which essentially tells us how much mixing has occurred and helps us re dose RhoGAM as needed. We should mention the physical exam is also critically important here. We want to look and feel for regular contractions. Also do a vaginal exam.

Vaginal bleeding would be suggestive of placental abruption, which can be extraordinarily dangerous and is the number one cause of fetal

demise in trauma patients. And look for clear fluid as well, which could suggest ruptured membranes. These patients all need to be admitted for observation.

Typically that is a four hour or more period, which includes fetal heart monitoring. All right, Kevin, let's move on to benign gynecologic disease. What are common signs and symptoms of endometriosis? Yeah, so you're gonna have the dysmenorrhea, the dysperionia, and the infertility. And what might you see intraoperatively, for instance, if you're doing a laparoscopic procedure?

Yeah, this isn't terribly uncommon to see. You'll see blue tinged masses on laparoscopy or endoscopy. And how do we treat endometriosis? Yeah, many of these patients can improve with oral contraceptive use. But if medical management isn't adequate, you can do surgical excision or ablation of the endometriosis.

Okay. Let's move on to a patient who has pelvic inflammatory disease. How are these patients presenting? Yeah, so they'll have, potentially have fevers, nausea, vomiting, vaginal discharge,

abnormal uterine bleeding, dysperionia, and cervical motion tenderness. Right, and how do we manage these patients?

Generally with broad spectrum antibiotics. Yeah, what antibiotics are you going to use specifically? I think clindamycin and aminoglycosides. Okay, and if antibiotics aren't cutting it or they're particularly sick or have a large abscess? Then you have to do, consider doing an image guided percutaneous drainage versus surgical drainage.

Yeah. Alright, let's talk gynecologic malignancies. So what characteristics of an ovarian cyst are suspicious for malignancy? Yeah, if it has thick septations, if it has solid components. If it has papillary projections or if it has vascularity within the solid components, or if it's very large, greater than 10 centimeters.

Alright, so if you have any mix of those high risk features, what's the treatment? Oophorectomy with intraoperative frozen section to evaluate for ovarian cancer. Okay, and if you don't have any of those high risk features, what are you going to do? Ultrasound surveillance. And if it's growing or develops suspicious characteristics, at that point you move on to surgery.

How about

ovarian torsion? How is this managed? So this is more common in patients that have large ovarian cyst, greater than five centimeters. So management is detour and ovarian conservation if possible. And what if you see necrosis intraoperatively, then you do the salinga ectomy. That's right.

Alright. What are risk factors associated with ovarian cancer? So, NOLA parody, late menopause, early menarchy, PCOS endometriosis. Smoking, family history of ovarian, breast, urine, or colon cancer and hereditary cancer syndromes, which is bracket and Lynch. Yeah. So on the exam, mostly you're going to get these kind of tips or, or hints like Nola parody, late menopause and early menarche.

At least one of those will pop up. And so you can start thinking about risk factors for ovarian cancer. If you're receiving that type of information on the exam on the flip side, what are the, what decrease risk for ovarian cancer? So if they've had taken OCPs, oral contraceptives

bilateral tubal ligation, previous pregnancies and breastfeeding, right?

So the complete opposite when it comes to exposure to, to a hormone. So again, low risk for ovarian cancer, it's previous pregnancies, breastfeeding, et cetera. So what are the components of the typical management for patients? Again, this is a, obviously for our purposes, a, a big overview, but we'll, how do we manage patients with ovarian cancer?

So a total abdominal hysterectomy with bilateral oophorectomy with pelvic and para aortic lymph node dissection and omentectomy pelvic washes and cytology of the diaphragm. Yeah. So you're going, you're going big time and specifically what chemotherapy is used to treat ovarian cancer. Cisplatin and Paclitaxel.

Okay. Let's move on to endometrial cancer. So what are the risk factors for endometrial cancer? So unopposed estrogen, nulliparity, later in life, first pregnancy, obesity, and use of tamoxifen. Right, so you mentioned, you said unopposed estrogen, so high estrogen exposure over the lifetime of that patient.

And what is the typical presenting symptom, or how do these patients typically present endometrial cancer? Yeah, so postmenopausal vaginal bleeding is a concerning sign. Right. And how are you going to work them up? So uterine ultrasound with endometrial biopsy. Okay. And if that biopsy shows endometrial cancer, how are we going to manage it?

So a total hysterectomy with bilateral salpingo oophorectomy. And you can also consider the pelvic and periordic lymph node dissection if it's high risk for metastatic disease. Sure. And random, random bit of trivia here. So which lymph nodes does cervical cancer spread to first? The obturator nodes.

Okay. All right. We did a great job covering those high yield points. You typically have about what, two questions. on the ab side that cover OBGYN type content. So let's move on to quick hits. Kevin, what's the most common site of endometriosis? The ovaries. Okay, what are other common sites? The utero sacral ligaments in the pouch of Douglas.

Okay, most common site of an ectopic pregnancy? Fallopian tube.

Alright, so a patient who presents with liver failure, anecytes and they're postpartum. What's what are you thinking about in this patient? I'm worried about postpartum thrombophlebitis of the hepatic vein in the IVC. Yeah, how do we treat those patients?

Heparin and antibiotics. Okay. What are contraindications to estrogen therapy? So, known diagnosis of endometrial breast cancer or abnormal uterine bleeding of unknown ideology. Yeah, and also patients who are at high risk for thromboembolic disease. Alright, what is the most common complication of laparoscopic hysterectomy?

Bladder injury. Okay, what is the most common site of ureteral injury during hysterectomy? The distal ureter at the level of the uterine arteries. Yeah, and that's typically managed with re implantation, and we do have a full episode as well on urology and urologic issues. What is the most common gynecologic malignancy?

Endometrial cancer. Okay, is there a subtype that is particularly bad? Yeah, clear cell. What's the leading gynecologic cause of death?

Ovarian cancer. And again, that subtype that's particularly bad is clear cell for ovarian cancer as well. What's the name given to a stomach cancer met to the ovary? Yeah, this is the Kruckenberg tumor.

Okay, and on pathology, what do you see? The signet ring cells. What is the syndrome in which an ovarian fibroma causes ascites and hydrothorax? This is Myg syndrome. Yeah, and how do you treat that? You excise the fibroma. Okay, last question. What is the most common extracolonic tumor in Lynch syndrome?

Endometrial cancer. Fantastic. We hope that was helpful. Dominate the day.