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Volledige samenvatting gynaecologie boek 1

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Course
Verloskunde-gynaecologie

Institution
Katholieke Universiteit Leuven (KU Leuven)

Volledige samenvatting van boek 1 van gynaecologie voor het vak verloskunde-gynaecologie. Gemaakt op basis van handboek en eigen lesnotities. Bevat alle te kennen leerstof voor het examen.

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Uploaded on September 5, 2023
Number of pages 97
Written in 2023/2024
Type Summary

verloskunde
gynaecologie
verloskunde gynaecologie
geneeskunde
master geneeskunde
ku leuven

Institution
Katholieke Universiteit Leuven (KU Leuven)
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Geneeskunde
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Verloskunde-gynaecologie

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GYNAECOLOGIE
Inleiding ....................................................................................................................................................... 7
1. Vulvaire pathologie ................................................................................................................................. 9
1.1. Gynatresie/stenose hymen/hematocolpos ..................................................................................... 9
1.1.1. Indeling gynatresie .................................................................................................................... 9
1.1.2. Stenose van het hymen ............................................................................................................ 9
1.2. Hematoom van de vulva .................................................................................................................. 9
1.3. Niet-neoplastische vulvaire afwijkingen ........................................................................................ 10
1.3.1. Lichen sclerosus ...................................................................................................................... 10
1.3.2. Squameuze hyperplasie (leukoplakie) .................................................................................... 10
1.3.3. Andere dermatose .................................................................................................................. 10
1.4. Condylomata acuminata ................................................................................................................ 10
1.5. Vulvaire intra-epitheliale neoplasie (V.I.N.) ................................................................................... 11
1.6. Squameus vulvacarcinoom ............................................................................................................ 12
1.7. Andere maligne vulvaire tumoren ................................................................................................. 13
1.7.1. Melanoma vulvae.................................................................................................................... 13
1.7.2. Vulvaire Paget ......................................................................................................................... 13
1.7.3. Basocellulair carcinoom .......................................................................................................... 13
1.7.4. Carcinoom van de Bartholinklier ............................................................................................ 13
2. Vagina .................................................................................................................................................... 14
2.1 Goedaardige vaginaletsels .............................................................................................................. 14
2.2 Vaginacarcinoom............................................................................................................................. 14
3. Cervix uteri ............................................................................................................................................ 15
3.1. Goedaardige letsels van de baarmoederhals ................................................................................ 15
3.1.1. Cervicitis .................................................................................................................................. 15
3.1.2. Cervicale ectopie ..................................................................................................................... 15
3.1.3. Cervicale erosie ....................................................................................................................... 15
3.1.4. Cervicale transformatiezone................................................................................................... 15
3.1.5. Cervicale wratten .................................................................................................................... 15
3.1.6. Cervicale poliepen ................................................................................................................... 16
3.1.7. Cyste van Naboth .................................................................................................................... 16
3.2. Premaligne en maligne letsels van de baarmoederhals................................................................ 16
3.2.1. Premaligne letsels van de cervix: cervicale intra-epitheliale neoplasieën (CIN) of squameuse
intra-epitheliale letsels (S.I.L.)........................................................................................................... 16

1

, Definities ....................................................................................................................................... 16
Evolutie .......................................................................................................................................... 18
Leeftijd........................................................................................................................................... 18
Etiologie......................................................................................................................................... 18
Diagnose en screening .................................................................................................................. 19
Behandeling................................................................................................................................... 23
Follow-up na therapie van een CIN .............................................................................................. 23
3.2.2. Invasief cervixcarcinoom ........................................................................................................ 23
Voorkomen en etiologie ............................................................................................................... 23
Evolutie en metastasering ............................................................................................................ 23
Stadia ............................................................................................................................................. 24
Prognose ....................................................................................................................................... 24
Histologisch type ........................................................................................................................... 24
Symptomen ................................................................................................................................... 24
Bilan ............................................................................................................................................... 25
Therapie ........................................................................................................................................ 25
Recidief .......................................................................................................................................... 27
Follow-up van patiënten met cervixCA ........................................................................................ 27
4. Corpus uteri ........................................................................................................................................... 28
4.1. Endometrium ................................................................................................................................. 28
4.1.1. Goedaardige letsel van het endometrium ............................................................................. 28
Asherman syndroom ..................................................................................................................... 28
Poliepen......................................................................................................................................... 28
4.1.2. Endometriumhyperplasie ....................................................................................................... 29
Eenvoudige hyperplasie ................................................................................................................ 29
Complexe hyperplasie ................................................................................................................... 29
Atypische hyperplasie ................................................................................................................... 29
4.1.3. Endometriumcarcinoom ......................................................................................................... 30
Voorkomen.................................................................................................................................... 30
Risicofactoren................................................................................................................................ 30
Evolutie en metastasering ............................................................................................................ 31
Stadia ............................................................................................................................................. 31
Prognose ....................................................................................................................................... 32
Histologische types ....................................................................................................................... 32
Symptomen ................................................................................................................................... 32
Diagnose ........................................................................................................................................ 32

2

, Bilan ............................................................................................................................................... 33
Therapie ........................................................................................................................................ 34
Follow up ....................................................................................................................................... 34
4.2. Myometrium .................................................................................................................................. 34
4.2.1. Myomen .................................................................................................................................. 34
Eigenschappen .............................................................................................................................. 34
Epidemiologie................................................................................................................................ 35
Risicofactoren................................................................................................................................ 35
Therapie ........................................................................................................................................ 35
4.2.2. Gynaecologische sarcomen .................................................................................................... 36
Staging ........................................................................................................................................... 36
Histologie....................................................................................................................................... 36
Prognose ....................................................................................................................................... 36
Therapie ........................................................................................................................................ 36
4.3. Adenomyose................................................................................................................................... 37
4.3.1. Prevalentie .............................................................................................................................. 37
4.3.2. Anatomopathologie ................................................................................................................ 37
4.3.3. Symptomen en diagnose ........................................................................................................ 37
4.3.5. Behandeling ............................................................................................................................ 37
5. Ovariële tumoren .................................................................................................................................. 39
5.1. Symptomatologie, diagnose en behandeling van niet-neoplastische- en goedaardige
neoplastische ovariële tumoren ........................................................................................................... 39
5.1.1. Klachten................................................................................................................................... 39
5.1.2. Klinisch onderzoek .................................................................................................................. 40
5.1.3. Complicaties ............................................................................................................................ 40
5.1.4. Beleid ....................................................................................................................................... 41
5.2. Niet-neoplastische tumoren .......................................................................................................... 42
5.2.1. Folliculaire cyste ...................................................................................................................... 42
5.2.2. Corpus luteum cyste ............................................................................................................... 42
5.2.3. Polycystische ovaria (Stein Leventhal Syndrome) .................................................................. 42
5.2.4. Stromale hyperplasie en -hyperthecose ................................................................................ 42
5.2.5. Zwangerschapsluteoom .......................................................................................................... 43
5.2.6. Endometriosecyste ................................................................................................................. 43
5.3. Epitheliale neoplastische tumoren ................................................................................................ 43
5.3.1. Borderline tumoren ................................................................................................................ 43
5.3.2. (Invasief) ovariumcarcinoom .................................................................................................. 43
Voorkomen.................................................................................................................................... 43

3

, Etiologie......................................................................................................................................... 44
Evolutie en metastasering ............................................................................................................ 44
Histologische types ....................................................................................................................... 45
Prognose ....................................................................................................................................... 45
Symptomen ................................................................................................................................... 45
Preoperatief bilan ......................................................................................................................... 45
Therapie ........................................................................................................................................ 46
Follow up ....................................................................................................................................... 47
5.3.3. Kiemceltumoren...................................................................................................................... 47
Eigenschappen .............................................................................................................................. 47
Dysgerminoom .............................................................................................................................. 47
Endodermaal sinus tumor............................................................................................................. 48
Embryonaal carcinoom ................................................................................................................. 48
Niet gestationeel choriocarcinoom .............................................................................................. 48
Teratomen ..................................................................................................................................... 48
5.3.4. Sex cord stromale tumoren .................................................................................................... 48
Eigenschappen .............................................................................................................................. 48
Granulosa stromale tumoren ....................................................................................................... 49
Sertoli-stromale tumoren ............................................................................................................. 49
6. Bekkenbodem........................................................................................................................................ 50
7. Borst ...................................................................................................................................................... 51
7.1 Leerdoelen ...................................................................................................................................... 51
7.2 Anatomie ......................................................................................................................................... 52
7.3 Fysiologie ......................................................................................................................................... 53
7.4 Diagnostiek ...................................................................................................................................... 53
7.4.1 Anamnese ................................................................................................................................ 53
7.4.2 Klinisch onderzoek ................................................................................................................... 54
Algemeen ...................................................................................................................................... 54
Inspectie van beide borsten, axilla en borstbeen ........................................................................ 54
Palpatie van de borst .................................................................................................................... 55
Palpatie van de lymfeklierregio’s .................................................................................................. 55
7.4.3 Beeldvorming ........................................................................................................................... 56
Mammografie ............................................................................................................................... 56
Echografie ..................................................................................................................................... 58
MRI ................................................................................................................................................ 59
Screening naar metastasen .......................................................................................................... 59

4

, 7.4.4 Cyto- en histopathologisch onderzoek .................................................................................... 59
7.4.5 Triple diagnostiek ..................................................................................................................... 60
7.5 Goedaardige borstproblemen ........................................................................................................ 60
7.5.1 (Voelbare) massa ..................................................................................................................... 60
Fibroadenoom ............................................................................................................................... 61
Phyllodes tumor ............................................................................................................................ 61
Borstcyste ...................................................................................................................................... 62
Intraductaal papilloom .................................................................................................................. 62
Radial scar ..................................................................................................................................... 63
7.5.2 Infectieuze aandoeningen ....................................................................................................... 63
Ontstekingen tijdens lactatie ........................................................................................................ 63
Ontstekingen buiten de lactatieperiode....................................................................................... 63
7.5.3 Tepelvochtverlies ..................................................................................................................... 64
Fysiologisch ................................................................................................................................... 64
Pathologisch .................................................................................................................................. 65
7.5.4 Gynaecomastie......................................................................................................................... 65
7.5.5 Pijn aan de borst(en) ................................................................................................................ 66
Cyclische mastopathie .................................................................................................................. 66
Niet-cyclische mastopathie........................................................................................................... 67
7.6 Borstkanker ..................................................................................................................................... 67
7.6.1 Epidemiologie........................................................................................................................... 67
7.6.2 Etiologie en pathologie ............................................................................................................ 67
7.6.3 Risicofactoren .......................................................................................................................... 69
7.6.4 Familiaal risico en genetische factoren bij borstkanker .......................................................... 69
7.6.5 Beleid bij hoog risico ................................................................................................................ 70
Screening ....................................................................................................................................... 70
Preventieve heelkunde als primaire preventie ............................................................................ 70
Chemopreventie ........................................................................................................................... 71
7.6.6 Prognose van het mammacarcinoom ..................................................................................... 71
7.6.7 Klinische en pathologische stadiering bij borstkanker ............................................................ 72
7.6.8 Chirurgie bij niet-gemetastaseerde borstkanker .................................................................... 73
Inleiding ......................................................................................................................................... 73
Borstchirurgie ................................................................................................................................ 73
Okselchirurgie ............................................................................................................................... 74
Reconstructie ................................................................................................................................ 75
7.6.9 Radiotherapie bij niet-gemetastaseerde borstkanker ............................................................ 75

5

, Indicaties voor radiotherapie........................................................................................................ 75
Dosissen ........................................................................................................................................ 76
Technische aspecten ..................................................................................................................... 76
Nevenwerkingen van radiotherapie ............................................................................................. 76
7.6.10 Systeemtherapie bij niet-gemetastaseerde borstkanker ..................................................... 77
Soorten systeemtherapie ............................................................................................................. 77
Wanneer systeemtherapie gebruiken bij vroegtijdige borstkanker? .......................................... 79
7.6.11 Behandeling van in situ borstkanker ..................................................................................... 80
7.6.12 Opvolging na borstkanker ...................................................................................................... 80
7.6.13 Lokaal/locoregionaal herval................................................................................................... 81
7.6.14 Gemetastaseerde borstkanker .............................................................................................. 81
8. Infecties ................................................................................................................................................. 83
8.1 Definitie ........................................................................................................................................... 83
8.2 Inleiding ........................................................................................................................................... 83
8.3 Seksueel overdraagbare aandoeningen (SOA) ............................................................................... 83
8.3.1 Chlamydia trachomatis ............................................................................................................ 83
8.3.2 Herpes simplex virus ................................................................................................................ 84
8.3.3 Humaan papillomavirus ........................................................................................................... 84
8.3.4 Hepatitis B virus ....................................................................................................................... 85
8.3.5 Trichomonas............................................................................................................................. 85
8.4 Gynaecologische infecties............................................................................................................... 85
8.4.1 Vulvitis en bartholinitis ............................................................................................................ 85
8.4.2 Vaginitis .................................................................................................................................... 86
Bacteriële vaginose (niet-specifieke vaginitis, I)........................................................................... 87
Candidiasis (schimmels) ................................................................................................................ 88
Trichomoniasis .............................................................................................................................. 89
8.4.3 Cervicitis ................................................................................................................................... 89
8.4.4 Supracervicale infecties ........................................................................................................... 89
9. Endometriose ........................................................................................................................................ 92
9.1 Definitie ........................................................................................................................................... 92
9.2 Pathogenese van endometriose ..................................................................................................... 92
9.2.1. Retrograde menstruatie, coeloom metaplasie en inductietheorie ....................................... 92
9.2.2. Genetische factoren................................................................................................................ 92
9.2.3. Inflammatoire en immunologische factoren.......................................................................... 92
9.3. ((Prevalentie van endometriose)) .................................................................................................. 92
9.4. Diagnose van endometriose .......................................................................................................... 92

6

, 9.4.1. Symptomen ............................................................................................................................. 92
Pijn ................................................................................................................................................. 93
Subfertiliteit .................................................................................................................................. 93
Extrapelviene endometriose......................................................................................................... 93
9.4.2. Klinisch onderzoek .................................................................................................................. 93
9.4.3. Technische onderzoeken ........................................................................................................ 94
9.4.4. Geen serumtest voor endometriose ...................................................................................... 94
9.4.5. Laparoscopische en histologische aspecten .......................................................................... 94
9.4.6. Classificatie volgens de revised American Fertility Society (1997) ........................................ 95
9.5. Spontane evolutie .......................................................................................................................... 95
9.6. Behandeling van endometriose ..................................................................................................... 95
9.6.1. Chirurgische behandeling ....................................................................................................... 95
Pre-operatieve voorbereiding ...................................................................................................... 95
Principes ........................................................................................................................................ 95
Effect ............................................................................................................................................. 96
9.6.2. Medische behandeling............................................................................................................ 96
Progestagenen .............................................................................................................................. 96
Orale contraceptiva ...................................................................................................................... 96
LHRH agonisten ............................................................................................................................. 97
Levonorgestrel houdend IUD ........................................................................................................ 97
Efficiëntie van medische behandeling .......................................................................................... 97
9.7. Medisch begeleide bevruchting..................................................................................................... 97

INLEIDING
- Curretage
• = D&C = dilatatie en curretage
• Eerst dilatatie cervicaal kanaal tot ongeveer 10 mm
• Daarna curretage endometriu met currete met een diameter van normaalgezien 10 mm
• Vaak gefractioneerde curretage
o Eerst endocervicaal kanaal
o Daarna cavum van corpus van uterus
- Hysteroscopie
• Eerst dilatatie cervix, daarna scoop in uterus
• -> visualisatie kleine afwijkingen vb poliepen, hyperplasie van endometrium,
subendometriale myomen
• Cavum van uterus w opgeblazen onder druk met vloeistog
• Soms aanvulling van diagnostische hysteroscopie met operatieve hysteroscopie
o Biopsies, poliepectomie, verwijderen intra-uterien septum of volledige
resectie/coagulatie van endometrium (hysteroscopische endometriumablatie)

7

,- Laparoscopie
• Meestal via navel
• Opblazen abdomen met CO2
• Hysterectomie, lymadenectomie, oöforectomie
• Robot-geassisteerd: 3D en meer beweeglijke instrumenten + chirurg bedient zelf de
camera -> mogelijk om ingrepen uit te voeren die moeilijk via een gewone laparoscopie
kunnen
- Laparotomie
• Snedes
o Mediaan: van navel naar pubis
o Horiontaal (pfannenstiel of bikini insnede)
- Hysterectomie
• Via laparotomie (abdominaal) of via vaginale weg
• Of laparoscopisch geassisteerde vaginale hysterectomie
• Of totaal laparoscopisch +/- robot
- Totale hysterectomie = verwijderen corpus en cervix van uterus
- Subtotale hysterectomie = enkel verwijderen corpus uterus
• Kan niet vaginaal, wel via laparotomie of laparoscopisch
- Radicale hysterectomie (Wertheim-Meigs)
• Bij cervixCA
• Verwijderen: uterus + cervix + parametria + deel van vagina (4cm) + pelviene lymfeklieren
- Bilaterale salpingo-oöferectomie (BSO) en unilaterale salpingo-oöferectomie (USO)
• Verwijderen salpingen (tubae) en ovaria (ooferectomie)
- HT + BSO = totale hysterectomie met bilaterale salpingo-oöferectomie

8

, 1. VULVAIRE PATHOLOGIE

1.1. GYNATRESIE/STENOSE HYMEN/HEMATOCOLPOS
- Gynatresie = toestanden die gepaard gaan met afsluiting van de genitale tractus, op eender wlk
niveau
• Afsluiting kan verworven of congenitaal zijn
1.1.1. INDELING GYNATRESIE
- Congenitaal, thv:
• Hymen
o Stenose van hymen meest frequente congenitale pathologie -> S/ en R/ gelijkaardig
voor andere congenitale vormen
• Cervix
• Vagina
- Verworven, thv cervix door:
• Seniele genitale atrofie
• Maligne aandoeningen
• RT/cauterisatie
• HK
1.1.2. STENOSE VAN HET HYMEN
- D/
• Meestal pas na menarche
- S/ door opstapeling van menstrueel bloed
• Bij menstruatie -> onderbuikspijn, bij elke cyclus meer uitgesproken
• Zeer vele bloed opgestapeld -> uitzetting cavum uteri -> palpabele massa in onderbuik ->
distentie van blaas door urineretentie kan ontstaan
- Gevolgen
• Cyclische onderbuikspijn en zeer aanzienlijke hoeveelheid bloed w opgestapeld
• -> distentie van vagina (hematocolpos)
• -> daarna distentie van cervix, cavum uteri (hematometra)
• -> ten slotten ook distentie van tubae (hematosalpinx)
- R/
• Incisie/excisie van hymen en trage evacuatie van bloed onder strikt aseptische
omstandigheden

1.2. HEMATOOM VAN DE VULVA
- Oorzaken
• Traumatisch
• HK: ‘herstel’ operaties
• Episiotomie
• Ruptuur perineum
- S/
• Uitgesproken pijn: ernst afh van hoeveelheid opgestapeld bloed
• Reflexmatige inhibitie van mictie en/of defecatie (soms)
- R/
• Klein hematoom resorbeert spontaan

9

, • Grote bloedcollectie -> extirperen

1.3. NIET-NEOPLASTISCHE VULVAIRE AFWIJKINGEN
Oudere benamingen: vulvaire dystrofieën en krauroris vulvae (w niet meer gebruikt)
1.3.1. LICHEN SCLEROSUS
- Huidaandoening: vnl thv vulva en peri-anaal
- Verschrompeling, verdroging en lichenficatie van de huid
- D/
• Macroscopisch: dunne en witbleke huid, pigmentatie en haargroei verdwenen, atrofie
van labia (introïtus vaginae vernauwd)
• Klachten -> jeuk, dyspareunie, dysurie, secundaire infectie (krabletsels)
• Vulvoscopie met colposcoop en gerichte biopsie
• Hoger risico op ontwikkelen van CA (van plaveiselepitheel van vulva) -> jaarlijks grondige
inspectie van vulva
- DD/
• Infectie
• Vulvaire intra-epitheliale neoplasie (VIN)
• Allergische reacties
o Vrij frequent op condoom
o Zeep, wasproducten, parfums …
• NB vulvair uitdrogingseczeem
o Zeer frequent
o Door vaak wassen, zeep, parfums …
o R/
§ Zeer vermijden
§ Niet uitdrogende zeep (vb Balneum Hermal badolie en hydraterende crème)
- R/
• Lokale zeer sterke corticoide continue therapie: verlaagde incidentie van vulvaCA en
meest efficiënt tegen (vaak ondraaglijke) jeuk
o Vb dagelijks betamethasone of clobetasol
1.3.2. SQUAMEUZE HYPERPLASIE (LEUKOPLAKIE)
- Wit verheven letseltje -> biopsie (cave (pre)maligniteit
- R/
• Lokaal sterke corticoidecremes (vb hydrocortison, methylprednisolon)
1.3.3. ANDERE DERMATOSE
Zie cursus dermato
- Psoriasis
- Lichen planus
- …

1.4. CONDYLOMATA ACUMINATA
- Wratten thv vulva, vagina, perineum, anaal, cervicaal
- Meestal veroorzaakt door HPV 6 en 11
- Overdracht
• Venerisch

10

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