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Paediatric / Adolescent Gynaecology - Coggle Diagram
Paediatric / Adolescent Gynaecology
Common Presentations
Abnormal Uterine Bleeding
Puberty
Anoalies
Emergencies
Abnormal Uterine Bleeding
Definition
Describes irregularities in the menstrual cycle involving frequency, regularity, duration and volume outside of pregnancy
Epidemiology
1/3 will experience abnormal uterine bleeding
Most commonly occuring at menarche / perimenopausea
Normal Parameters in adolescents
Frequency 21-45 days
Duration 3-7 days
Volume 5-18ml
Indications for Investigation
Fhx / Phx of excessive bleeding
Epistaxis
Dental work
Minial response to 1st line therapies
Significant breakthrough bleeding
Investigations
Bloods
FBC
VwF actvity and antigen
Coag
Factor 8
Platelet function
TSH
USS / exam not indicated - not usualyl structural problem
Treatment
Depends on underlying cause
Abnormal Puberty
Types
Precocious (central or peropheral)
Delayed
Epidemiology
Average begin at age 10-11 and complete at ages 15-17
Indications for investigation
Signs of puberty before 8yo
No menarch 15yo
No secondary sex characteristocs at 13
Central Precocious Puberty
Process begins too slow, pattern and timing of steps otheriwse normal
Pathophysiology
GnRH released and causes secretion of FSH / LH
Causes
Majority no identifiable cause
CNS tumour
Congenital brain defect
Hydrpcephalus
Hamartoma - benign tumour
Radiation / injury to CNS
McCune-Albright syndrome
Congenital adrenal hyperplasia
Hypothyroidism
Management
GnRH Analogue
Freezes process until age of puberty
IM every 3 months
McCune Albright Syndrome
Aromatases inhibitor
Genetic staging and scrrening
Peripheral Precocious Puberty
Occures without the involvement of GnRH, associated with peripheral oestrogen producion
Causes
Adrenal galnd tumour secreting oestrogen / testosterone
Pituitary tumour secreting oestrogen / testosterone
McCune Alright syndrome
Iatrogenic oestrogen / testosterone (gels / ointments /lavender)
Ovarian cysts / tumours
Management
Treat cause
Precocious Puberty
Clinical Features
Short height
Social and emotional problems - self consiousness
Assessment
History
Vaginal bleeding
Pubic hair
Headaches / visual changes
Physical exam
Height and weight
Tanner staging
Clitoromegaly
Investigations
Bloods
FSH / LH
Oestradiol
Free T4 + TSH
Prolactin
Management
McCune Alb
Delayed Puberty
Causes
Constitutional
Structural anomaly / blockage
Chronic disease (CF)
Endocrinology
Chromosomal / genetic (eg turners)
Investigations
Bloods
FSH / LH
Oestrodiol
Free T4 / TSH
Prolactin
DEA-S
Coeliac screen
ESR
CMP - comprehensive metabolic screen
Karyotyping
Besides
HCG - r/o pregnancy in amenorrheoa
Imaging
Pelvic transabdominal USS
Anomalies
Types
Embryology - MRKH
Mullerian anomalies - Uterus, tubes , upper vagina
Hymen
Associations
Mullerian anomalies
Investigations
Imaging
Renal USS
Special tests
Scoliosis survey
Refer to Lecture for Case Studies
Emergencies
Straddle Injuries
Differentiate from SA
History and who tells it
Examination
Usually saddle injuries only cause trauma to external vulva and perineum - rarely hymen / vagina
Consistency of injury with abuse
Haematoma
Management
Analgesia
Ice packs
BAths
Ovarian Torsion
Epidemiology
Rare - 0.02%
Up to 2.7% of all causes of abdo pain in children
Peaks
Neonatal / antenatal
9-14 yo
Surgical emergency
Management
Analgesia
Causes
Long ovarian ligaments - premenarchal
Ovarian cyst - postmenarchal
Associated pathologies
Begnin ovarian cysts
Begnin neoplasms
Para00varian / Paratubal
Malignancy
Presentation
Sevre intermittent pain
Sudden onset
Very tender may be gaurding/ rebound / distension
N/V
Tachycardia
Palpable mass
Pyrexia
Elevated WCC
Differentiation from Appendicitis
ovarian torsion is
Less likely to have anorexia
Less likely to have gaurding
Less likely to have elevated CRP
Less likely to have leukocytosis
More likely to have palpable mass
Investigations
Imaging
US
Most sensitive and specific
Noninvasive, accessible, cost effective
Transabdominal - fully distended bladder
Findings
Peripheral follicles
Reduced blood flow
Management
Lap Detorsion
Cystectomy?
May be beneficial at time of detorsoin
Oophoropexy
Securing ovary to prevent torsion - shortening of ovarian ligament
