Structures Cases- Gyn

Question 1

Tubal ectopic with fluid in the cul de sac. VSS.
-what is your next step?
-you enter abdomen laparoscopically and can’t see, what do you do next?
-once you have identified the bleeding, do you finish laparoscopically?
-do you performa salpingostomy vs. salpingectomy

Answer 1

1. Discuss findings with patient and recommendation to proceed with Dx Lscope due to concerns for ectopic rupture, consents for surgery and blood. Labs: HB/ blood type
2. Irrigation and suction out fluid. IF can’t, then proceed with Laparotomy
   - yes, could finish laparoscopically if visualization adequate

Salpingectomy is standard if:
tube has ruptured or damaged, bleeding uncontrolled,
large gestation > 3 cm
-avoids persistence of trophoblastic tissue (with salpingostomy)

Salpingostomy preferred if: CL tube damaged and desire future child bearing or absent CL tube

Question 2

Ectopic surgery –> when would you covert to laparotomy?

Answer 2

1. bleeding uncontrolled laparoscopically, patient becoming HD unstable, adnexal adhesive disease so extensive beyond expertise, active bleeding prevents ID of site

Question 3

Positive pregnancy at 8 weeks with large bluish cervix
1) DDX
2) Cervical pregnancy management

Answer 3

1. large nabothian cyst, cervical cancer, congenital anomaly of cervix, cervical malignancy. leiomyoma on cervix
   2) US- hour glass shaped uterus and ballooning of the cervical canal.
   MFM Referrral. no not check cervix.

If HD stable- MTX first line, excision second

Question 4

What is the pathology report going to say about a molar pregnancy?

Answer 4

hydropic placental changes

Question 5

You identify a GTN. What do you do next?
1- evaluation
2- labs
3-imaging
4- treatment

Answer 5

1. post molar surveillance and not a decrease in your HCG values by 10%….

History: assess time from interval pregnancy, type of pregnancy, any previous treatment, is this HCG rise due to a new pregnancy..? Get US

2. CBC, CMP, HCG pre treatment
   3) Gyn onc referral. Discuss what imaging they would like. Anticipate
3. CT chest, abd, pelvis. MRI of brain
   4- treatment based on if it is non metastatic vs. metastatic with good/bad prognosis.

Question 6

You perform an RSO for a complex adnexal mass (that you thought was benign pre-op).
Intraop- you suspect malignancy
What do you do and how do you counsel the patient if the pathologist looses the specimen?

Answer 6

1. Since I suspected malignancy intra-op, I consulted gyn on intra-op. While waiting,
   -pelvic washings,
   -thorough exam of pelvic viscera, peritoneal surfaces, and bowel for caking and obtained biopsies of suspicious areas
   -primary specimen was sent for frozen (lost during en route), so you can obtain additional specimen
   -with gyn onc, performed the pelvic lymphadenoctomy

-tell patient that there was a loss of opportunity for definitive histologic diagnosis, however, I carefully did the steps above to do a complete clinical evaluation of the above. I am referring you to gyn onc for further review/discussion of treatment