GYN-Adnexal masses Flashcards
conditions that CA-125 can be elevated
fibroids, endometriosis, PID, ascites, other inflammatory diseases
50% of stage 1 ovarian cancer have normal CA125
adnexal mass in teenager
asymptomatic functional cysts up to 10 cm can be managed expectantly with serial ultrasound imaging
MC adnexal mass in pregnancy
mature cystic teratomas, paravorian cysts, and corpus luteum cysts
malignancy percentage in pregnant patients with persistent masses
10%
most common malignancies in reproductive age women
germ cell and sex cord stromal
highest risk of torsion in pregnant patients
if mass is 6-8 cm and between 10-16 weeks when uterus starts to grow rapidly
risk for ovarian cancer in general population
1 in 70
when to refer to onc in older patient with adnexal mass
- Ascites
- Evidence of mets
- Elevated score on formal risk assessment
- Premenopausal patient with very elevated CA-125 (>200)
- Postmenopausal patient with elevated CA-125 (>35)
- Fix/nodular pelvic mass
how to manage adnexal mass in older patient
<10 cm, < 5 cm, > 5cm,
1) if asymptomatic and less than 10 cm, repeat imaging in 4-6 months. See resolution in 2/3 of patients
-can observe asymptomatic simple cysts up to 10 cm even in menopausal patients (if nl CA125)
2) If <5 cm and normal CA 125 and multilocular or solid/cystic –> can repeat imaging and CA 125 in 4 weeks. If size or CA 125 increase, then surgery. if stable or decrease in size and CA125, repeat imaging in 3-6 months. If continues to be stable for 18-24 months, then you can stop
3) if >5 cm (5-10 cm), papillary, or with ascites, then need to refer to gyn onc for surgery
Management of TOA
-IV antibiotics for at least 24 hours, resolution of fever for more than 24 hours and improvement in pain. Then complete 14 day course of doxy and flagyl
-surgery in menopausal woman with pelvic abscess bc of risk of underlying malignancy
TOA and IUD
can leave IUD in place. If not improving in 48-72h with IV antibiotics, then remove it
if TOA fails to improve with IV antibiotics
if fails to improve with IV antibiotics in 48-72 hours, then CT/US guided drainage or surgery
-transvaginal drainage and antibiotics has success rate of 90-93%
-approximately 25% of cases fail to improve with just IV antibiotics’
-abscess <10 cm treated with drainage had shorter hospital stay and less likely to require surgical intervention
How to treat cervical ectopic pregnancy
single or multi dose methotrexate is treatment of choice
If fetal cardiac activity present, intra amniotic injection of KCL
DC carries risk of hemorrhage
UAE may be useful preop or to manage acute heavy bleeding
How to manage c scar pregnancy
-medical management (intragestational MTX)
-minimally invasive techniques (wedge resection)
-surgical treatment
-UAE with DC
-gravid hysterectomy
recurrence rate of c scar pregnancy
5-40%
recurrence rate of ectopic with
1 prior, 2 prior
Tubal surgery
tubal ligation
ART
IUD
1 prior: 10%
2 prior: 25%
Tubal surgery: 20%
Tubal ligation: 50%
ART: 5%
IUD >20% with LNG, <20% with Cu
if you have a SAB, how much should your HCG decrease by in 48
21-35%
MOA for MTX
folate antagonist, binds to dihydrofolate reductase, interrupts synthesis of purine nucleotides and amino acids inhibiting DNA synthesis and repair and cell replication
For PUL, if bHCG decreases by XXX after MVA, indicative of likely intrauterine process
50% in 12-24h
absolute and relative contraindications to MTX
absolute: IUP, immunodeficiency, anemia/leukopenia/thrombocytopenia, allergy to MTX, active pulm dz, active peptic ulcer dz, hepatic dysfunction, renal dysfunction, breastfeed, c/f ruptured ectopic, hemodynamically unstable, inability to fu
relative: +FHT, high initial HCG (>5k), >4cm in size, refusal to accept blood transfusion
2 dose MTX regimen and when to consider
consider if HCG >3000 or mass >2 cm.
50 mg/m2 body surface area on day 1 and day 4.
After 4 doses consider surgery
HCG should drop >15% between days 4 and 7 after treatment, >15% weekly after
multi dose MTX regimen
1 mg/kg on days 1, 3, 5, 7, with leucovorin 0.1 mg/kg on days 2, 4, 6,8
recommended for cornual/cervical pregnancies when managed medically
check hCG on either odd days, after the day 1 administration (3, 5, 7). On whichever odd day, the hCG declined >15%, no further mtx administered. Weekly monitoring
heterotopic pregnancy rate
spontaneous?: 1:30,000
IVF: 1.5/1000
cyst aspiration recurrence rate
44% at 6 months for pre menopausal woman, 25% menopausal
Torsion ovarian function
preserved in >90% of cases by 3 months
tumor markers for
mucinous epithelial tumor
endodermal sinus tumor
choriocarcinoma and germ cell
granulosa cell tumor
dysgerminoma
mucinous: CEA
endodermal: AFP, hCG
chorio: bHCG, AFP, +/- LDH
granulosa: estrogen and inhibin
dysgerminoma: LDH, hCG
adnexal mass is post menopausal patient workup
H&P
ultrasound
tumor markers
CT or MRI
laparoscopy or laparotomy
if suspicious for malignancy- refer to gyn onc
indications for inpatient treatment of PID
pregnancy
failed outpatient management
severe disease
suspected abscess
unclear diagnosis
generalized peritonitis
temp >38.3
WBC >15k
inability to tolerate PO or fu
risk and benefits of BSO
don’t do before 55-65 yo
increased risk of cardiovascular disease, nega impact on bone health, cognitive function and overall mortality
removal reduces risk of ovarian ca, put still possible from pelvic peritoneum
Also reduces risk of breast cancer (if removed premenopausal)
