Gynaecology Pg No 131 -140
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Questions and Answers

What is one of the key pre-operative checks before a myomectomy?

  • X-ray of the abdomen
  • Urine analysis
  • MRI of the pelvis
  • Endometrial biopsy (correct)

    • The recurrence rate of myoma after surgery is 10-15%.

    False

    What is the primary function of Boney's myomectomy clamp during surgery?

    Reduce blood loss

    The recurrence rate of myoma is between ____ percent.

    <p>5-10</p> Signup and view all the answers

    Match the surgical instruments with their uses:

    <p>Boney's Myomectomy Clamp = Reduce blood loss Sponge Holding Forceps = Clamp ovarian artery Myoma Screw = Hold the fibroid during surgery</p> Signup and view all the answers

    What is the preferred investigation for diagnosing a submucous fibroid?

    <p>Saline infusion sonography (SIS)</p> Signup and view all the answers

    MRI is commonly needed to diagnose fibroids.

    <p>False</p> Signup and view all the answers

    What management is recommended for a type 2 submucous fibroid with a complaint of infertility?

    <p>Laparoscopic myomectomy</p> Signup and view all the answers

    For a bilateral cornual intramural fibroid with complaints of infertility, the management is __________.

    <p>Laparoscopic myomectomy</p> Signup and view all the answers

    Match the types of fibroids with their recommended management options:

    <p>Type 0 = Hysteroscopic myomectomy Type 1 = Hysteroscopic myomectomy Type 2 onwards = Laparoscopic myomectomy B/L cornual intramural fibroid = Laparoscopic myomectomy</p> Signup and view all the answers

    Which type of myomectomy is suitable for Submucosal fibroids?

    <p>Hysteroscopic myomectomy</p> Signup and view all the answers

    A hysterectomy is performed when the family is not complete.

    <p>False</p> Signup and view all the answers

    What is the main cause of pelvic pressure symptoms related to fibroids?

    <p>Large size of fibroid</p> Signup and view all the answers

    Myomectomy involves the removal of fibroids while leaving the ______ behind.

    <p>uterus</p> Signup and view all the answers

    Match the type of fibroid with its recommended treatment:

    <p>Submucosal fibroid = Hysteroscopic myomectomy Type 2 fibroid (≥ 5 cms) = Laparoscopic myomectomy Intramural fibroid = Laparoscopic myomectomy Family complete = Hysterectomy</p> Signup and view all the answers

    Which ligament is considered one of the strongest ligaments supporting the uterus?

    <p>Cardinal ligament</p> Signup and view all the answers

    The broad ligament provides essential support to the uterus.

    <p>False</p> Signup and view all the answers

    What is the angle of anteversion between the vagina and the cervix?

    <p>90°</p> Signup and view all the answers

    The ligament that is a secondary support of the uterus is the ______.

    <p>round ligament</p> Signup and view all the answers

    Which of the following is NOT a part of the broad ligament?

    <p>Ovarium</p> Signup and view all the answers

    The broad ligament is a true ligament.

    <p>False</p> Signup and view all the answers

    Match the following ligaments with their roles in supporting the uterus:

    <p>Pubocervical ligament = Supports the uterus Cardinal ligament = One of the strongest ligaments Uterosacral ligament = Ensures support alongside cardinal ligament Round ligament = Secondary support of the uterus</p> Signup and view all the answers

    Name one common risk factor for conditions related to the broad ligament.

    <p>Elderly multiparous females</p> Signup and view all the answers

    The broad ligament contains the fallopian tube, round ligament, and the __________ artery.

    <p>uterine</p> Signup and view all the answers

    Match the following risk factors with their corresponding descriptions:

    <p>Birth trauma = An event during childbirth that may lead to complications Obesity = Excess body weight that can increase intra-abdominal pressure Menopause = A stage in a woman's life when menstrual cycles cease Collagen abnormalities = Genetic conditions affecting connective tissues</p> Signup and view all the answers

    What is the first-line drug used in medical management for symptomatic fibroids?

    <p>Tranexamic acid</p> Signup and view all the answers

    It is safe to perform uterine artery embolization in patients who wish to conceive.

    <p>False</p> Signup and view all the answers

    What are the two types of imaging used for diagnosing fibroids?

    <p>Ultrasound and MRI</p> Signup and view all the answers

    The procedure used to treat fibroids by focusing high intensity ultrasound waves is called __________.

    <p>HIFU</p> Signup and view all the answers

    Match the type of drug with its category in fibroid treatment:

    <p>Tranexamic acid = First-line drug GnRH agonist = Second-line drug Danazol = Second-line drug Oral Contraceptives = First-line drug</p> Signup and view all the answers

    What is the cause of cervix prolapse?

    <p>Loss of support</p> Signup and view all the answers

    Inversion of the cervix is characterized by the fundus being visible.

    <p>False</p> Signup and view all the answers

    What is the appearance of the internal os in a normal gynecological condition?

    <p>Not visible</p> Signup and view all the answers

    The appearance of the cervix in prolapse is indicated by the os being __________.

    <p>visible</p> Signup and view all the answers

    Match the gynecological conditions with their key features:

    <p>Normal = Internal os not visible Prolapse = Internal os is visible Inversion = Fundus protrudes out</p> Signup and view all the answers

    Which of the following characteristics describes an Enterocoele?

    <p>Bulge at upper 1/3rd of posterior vaginal wall</p> Signup and view all the answers

    Level II of vaginal support is associated primarily with the upper 1/3rd of the vagina.

    <p>False</p> Signup and view all the answers

    What is the primary support structure for Level I of vaginal support?

    <p>Cardinal ligaments and uterosacral ligament</p> Signup and view all the answers

    A Rectocele is characterized by a bulge at the ______________ of the posterior vaginal wall.

    <p>lower 2/3rd</p> Signup and view all the answers

    Match the following levels of vaginal support with their characteristics:

    <p>Level I = Supports upper 1/3rd of vagina Level II = Uterocervical prolapse, Enterocele Level III = Lax perineum, Rectocele ±</p> Signup and view all the answers

    Which muscle is considered the most important for supporting the uterus?

    <p>Levator ani muscle</p> Signup and view all the answers

    The ischiocavernosus muscle contributes to the support of the uterus.

    <p>False</p> Signup and view all the answers

    Name one muscle that is part of the pelvic diaphragm.

    <p>Levator Ani or Coccygeus</p> Signup and view all the answers

    The __________ muscle and its components form the levator plate.

    <p>Levator Ani</p> Signup and view all the answers

    Match the following pelvic floor muscles with their primary characteristics:

    <p>Levator Ani = Most important muscle for uterine support Bulbospongiosus = Superficial muscle aiding in sexual function Coccygeus = Part of the pelvic diaphragm, assists with pelvic support Ischiocavernosus = Helps maintain erection in males</p> Signup and view all the answers

    What is classified as 3rd degree prolapse?

    <p>Leading point &gt; 1 cm below hymen</p> Signup and view all the answers

    A urethrocele is associated with the lateral wall of the anterior vagina.

    <p>True</p> Signup and view all the answers

    Define procidentia in terms of prolapse classification.

    <p>Procidentia refers to the condition where the entire uterus and cervix hang out from the hymen.</p> Signup and view all the answers

    A __________ is a prolapse of the bladder into the anterior wall of the vagina.

    <p>cystocele</p> Signup and view all the answers

    Match the types of vaginal prolapse to their related descriptions:

    <p>Cystocele = Prolapse of the bladder into the anterior vaginal wall Rectocele = Prolapse of the rectum into the posterior vaginal wall Omentocele = Prolapse of abdominal tissue through the vaginal wall Laxed Perineum = Weakening of pelvic support structures</p> Signup and view all the answers

    Study Notes

    Boney's Myomectomy Clamp

    • Boney’s myomectomy clamp is used during surgical procedures to reduce blood loss and clamp bilateral uterine arteries
    • Clamping is typically done for 20 minutes followed by a 10-minute release
    • Sponge holding forceps are used to clamp the ovarian artery
    • Myoma screw is used to hold the fibroid during surgery

    Fibroid Recurrence and Post-Operative Complications

    • The recurrence rate for myomas is 5-10%
    • Continued menorrhagia after surgery is 10-15%

    Management of Fibroids

    • Transvaginal Sonography (TVS) is used to investigate fibroids
    • Saline infusion sonography (SIS) is often a better option than TVS for diagnosing submucous fibroids
    • Hysteroscopy is also used for diagnosing submucous fibroids
    • MRI is rarely used for diagnosis, but can be helpful pre-operatively

    Management of Asymptomatic Fibroids

    • Observation is the recommended approach for most asymptomatic fibroids
    • For submucous fibroids and infertility, hysteroscopic myomectomy is used for type 0 and 1 fibroids, while laparoscopic myomectomy is used for type 2 and onwards
    • Laparoscopic myomectomy is also used for patients experiencing infertility and bilateral cornual intramural fibroids
    • Symptomatic submucous fibroids typically require surgery, while symptomatic intramural and subserosal fibroids are usually managed medically

    Pelvic Organ Prolapse Quantification (POP-Q) Classification

    • The POP-Q classification system classifies the degree of pelvic organ prolapse based on the position of the prolapsed organ relative to the hymen
    • The first degree is characterized by the leading point of the prolapse being greater than 1 cm above the hymen
    • The second degree is characterized by the leading point of the prolapse being less than 1 cm from the hymen on either side
    • The third degree is characterized by the leading point being greater than 1 cm below the hymen
    • Procidentia is a severe form of prolapse where the entire uterus and cervix hang outside the hymen

    Vaginal Prolapse Classification

    • The classification of vaginal prolapse is divided into anterior and posterior walls, with different types based on the level of the prolapsed tissue
    • Anterior wall:
      • Cystocele (upper 1/3)
      • Urethrocele (lower 1/3)
    • Posterior wall:
      • Omentocele (upper 1/3)
      • Rectocele (lower 1/3)
      • Laxed Perineum (middle 1/3)

    Surgical Procedures for Fibroids

    • Hysterectomy is the preferred surgical option for women who are done having children
    • Myomectomy is better for women who wish to have children in the future

    Pelvic Pressure Symptoms

    • Pelvic pressure symptoms are common in individuals with intramural or subserosal fibroids, often caused by the large size of the fibroid
    • Treatment includes drugs that can shrink the fibroids, such as continuous GnRH agonists and GnRH antagonists

    Infertility

    • Submucosal fibroids are often a contributing factor to infertility
    • Treatment typically involves surgery
    • Hysteroscopic myomectomy is used for type 0 and 1 submucosal fibroids
    • Laparoscopic myomectomy is used for type 2 or greater submucosal fibroids and for bilateral cornual intramural fibroids

    Myomectomy

    • Myomectomy is the surgical removal of fibroids while leaving the uterus intact
    • It is recommended for patients with infertility or who wish to have children in the future
    • Hysteroscopic myomectomy is used for type 0/1 submucosal fibroids, while laparoscopic myomectomy is used for type 2 or larger fibroids

    Broad Ligament

    • The broad ligament is a peritoneal fold that is incorrectly named a ligament
    • It consists of three parts:
      • Mesosalpinx
      • Mesovarium
      • Mesometrium
    • The broad ligament contains:
      • Fallopian tube
      • Round ligament
      • Ovarian ligament
      • Uterine artery
      • Ovarian artery

    Risk Factors and Classification of Pelvic Organ Prolapse

    • Pelvic Organ Prolapse (POP) is more common in elderly, multiparous women
    • Other risk factors include birth trauma, multiparity, menopause, instrumental delivery, increased intra-abdominal pressure, obesity, prolonged or obstructed labor, and collagen abnormalities
    • The POP-Q, Baden Walker, and other classification systems are used to define the degree of prolapse based on measurements from the hymen or introitus

    Symptomatic C/O HMB/AUB (Heavy Menstrual Bleeding/Abnormal Uterine Bleeding)

    • Submucous fibroids are often detected through USG with type 0/1 fibroids
    • Intramural or subserosal fibroids are often detected through USG with type 2 or greater, or 5 cm fibroids
    • Medical management of HMB/AUB includes first-line drugs like tranexamic acid, oral contraceptives (OCPs), and progesterone (oral or Mirena), and second-line drugs such as continuous GnRH agonists, GnRH antagonists, letrozole, danazol, and gestrinone
    • The principle of medical management is to reduce fibroid size or bleeding by targeting hormonal dependencies
    • Uterine artery embolization is used as an interventional method to stop bleeding, but is contraindicated in individuals who wish to conceive
    • HIFU (High Intensity Focused Ultrasound) is another interventional method that uses sound waves to coagulate and destroy fibroids
    • Hysteroscopy and laparoscopic myomectomy are surgical options used as a last resort
    • Absolute contraindications for these treatments include the desire to conceive, active pelvic inflammatory disease (PID), and malignant fibroids
    • Relative contraindications include postmenopausal status

    Gynecological Instrument Observation

    • The observations are likely related to a gynecological examination or the study of obstetric complications
    • A normal cervix displays a visible internal os during a gynecological examination
    • Pelvic organ prolapse is characterized by a visible internal os during a gynecological exam due to loss of support
    • Cervical inversion is characterized by the fundus protruding outward, and the internal os being invisible during a gynecological examination, often a latrogenic complication of labor

    Enterocoele vs Rectocele

    • An enterocoele is a bulging of the upper 1/3rd of the posterior vaginal wall during a pelvic exam
    • A rectocoele is a bulging of the lower 2/3rd of the posterior vaginal wall during a pelvic exam
    • An enterocoele has a positive cough impulse, while a rectocoele has a negative cough impulse

    De Lancys Levels of Support of the Vagina

    • De Lancys levels of support are used to classify the different levels and supports involved in vaginal prolapse
    • Level 1 supports the upper 1/3rd of the vagina and involves the cardinal ligament (CL) and uterosacral ligament (US)
    • Level 2 supports the middle 1/3rd of the vagina and involves the arcus tendinous fascia, perineal body, and surrounding muscles
    • Level 3 supports the lower 1/3rd of the vagina and mainly involves the urogenital diaphragm muscles
    • Vault refers to the portion of the vagina remaining after hysterectomy
    • Congenital elongation of the cervix refers to an elongated vaginal portion with a deep fornix

    Anatomical Supports of the Uterus

    • Pelvic diaphragm:
      • Consists of the levator ani and coccygeus (ischiococcygeus) muscles
      • These are voluntary muscles involved in defecation, urination, and childbirth
    • Pelvic floor muscles
      • Superficial muscles: ischiocavernosus, bulbospongiosus (bulbospongiosus), superficial transverse perinei
      • Deep muscles:
        • Muscles that do not support the uterus: ischiocavernosus, obturator internus, piriformis, ischiococcygeus
        • Muscles that do support the uterus: levator ani, deep transverse perinei, superficial transverse perinei, bulbospongiosus, external urethral sphincter
    • Levator plate (anococcygeal raphe): formed by the levator ani muscle
    • The levator ani muscle consists of the puborectalis, pubococcygeus, iliococcygeus, and coccygeus (ischiococcygeus) muscles
    • It is the most important support for the uterus
    • Damage to the puborectalis muscle can lead to pelvic organ prolapse
    • The pelvic floor hangs down like a hammock and attaches to the levator plate

    Angles

    • Angle of anteflexion: 120° - the angle between the cervix and the uterus
    • Angle of anteversion: 90° - the angle between the vagina and the cervix

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    This quiz covers essential aspects of surgical management techniques for fibroids, including the use of Boney's myomectomy clamp, diagnostic tools, and recurrence rates. Test your knowledge on the approaches for treating symptomatic and asymptomatic fibroids, as well as post-operative considerations.

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