O&G #2 Flashcards

Question

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Answer 1

D – Placenta percreta Placenta accreta broadly describes placental invasion into the uterine wall and is divided more specifically into placenta increta and placenta percreta (below). It is caused by over-invasion by the fetal trophoblast through the maternal decidual barrier when implantation occurs in the first trimester. Risk factors include previous retained placenta, previous Caesarean section, a history of previous dilation and curettage (D&C) or suction termination, placenta praevia, high parity, advanced maternal age and previous postpartum endometritis. Placenta increta invades the myometrium only. Placenta percreta invades the myometrium and the outer serosal layer of the uterus. It can invade adjacent structures including the bladder and bowel.

Answer 2

D – Intrauterine or systemic progestogens Progestogens are the most appropriate treatment as it offers her contraception and reduction in bleeding. She is not suitable for the combined oral contraceptive pill due to the combination of age and smoking habits and the other treatments listed do not provide contraception. Subjective menorrhagia is when women complain of heavy periods. Objective menorrhagia is .80 mL bloods loss per cycle. Only 50% of women who complain of heavy bleeding actually have over 80 mL of blood loss but subjective menorrhagia must still be treated. Sixty percent of women with objective menorrhagia develop anaemia. The main causes for menorrhagia are dysfunctional uterine bleeding, uterine pathology such as fibroids, and rarely medical conditions including clotting disorders. There are many different ways of administering progestogens and preparation used is down to personal choice. An oral formulation such as norethisterone (progesterone-only pill, trade name Micronor or Noriday) can be used starting on day 5 for 21 days and reduces bleeding by up to 80%. Progestogens can also be administered by injection every 8 or 12 weeks which can eventually lead to amenorrhoea if used for long enough, however these can give irregular and heavy bleeding for the first few months of use. An intrauterine device that delivers progestogen directly to the lining of uterus is available (Mirena). It can be kept in situ for 5 years and can reduce bleeding by 95% giving amenorrhoea in many women and also provides excellent contraception. Again irregular bleeding can be a problem particularly in the first 6 months and this must be explained to women prior to insertion otherwise there is a very high removal rate. Menstrual flow is reduced or stopped by destroying the endometrium by ablation. Hysteroscopic procedures include laser ablation, resection or coagulation using an electric roller ball. Microwave ablation, heat ablation and electrocautery are all non-hysteroscopic procedures. Pregnancy is contraindicated after ablation. This again would help with the menorrhagia but again would offer no contraception and the patient in this scenario may want more children.

Answer 3

E – Recall in 5 years The fact there is a premalignant phase for cervical cancer makes it suitable for screening, so the premalignant disease can be treated before the invasion occurs. Cervical screening aims to detect the precancerous lesion (cervical intraepithelial neoplasia [CIN]) on the cervix which requires a sample of cells from this area. The previous method, known as a smear test, used a spatula to scrape cells from the cervix which were then ‘smeared’ onto a slide and examined under a microscope. Liquid-based cytology (LBC) is the current practice. The spatula has been replaced by a brush which collects the cells from the cervix by five full circular rotations. The head of the brush is broken off into preservative fluid for transport to the laboratory. The sample is then spun to separate the cells and they are examined under a microscope. Cervical screening is best taken mid-cycle and is 99.7% specific and 80% sensitive. Screening on the National Health Service starts at age 25 and finishes at age 64. The frequency of recall varies with age to ensure a targeted and effective screening programme and is done via the general practice on a computer recall system. If a woman aged 25 to 50 years has a normal smear they are called back in 3 years. Once they are over 50 years, recall increases to every 5 years. Those over 65 are only screened if they have had recent abnormal tests or if they have not been screened at all since age 50. A woman may be recalled early for a number of reasons. If there are inadequate cells for the study the patient is recalled in 6 months. If a diagnosis of CIN I is made a repeat is needed in 6 months as these cells often revert to normal without any treatment. If on the repeat test the cells still show CIN I, colposcopy will be required. A single diagnosis of CIN II or III requires referral to colposcopy. Obviously a diagnosis of invasive carcinoma would require immediate specialist referral. Immunocompromised patients require annual screening. No more smears are necessary if the woman has had a hysterectomy for benign disease but if the hysterectomy was for CIN then vaginal vault smears are required.

Answer 4

B – Give antenatal anti-D prophylaxis 500 iu at 28 weeks

Answer 5

E – Serum triple test The triple test is a screening test for Down’s syndrome and spina bifida. A number of serum markers are used in combination with the age of the mother and confirmed gestation of the pregnancy to give a risk of Down’s syndrome. Increasing maternal age is the strongest risk factor. The serum markers used in the triple test are alpha-fetoprotein (AFP), oestriol and human chorionic gonadotrophin beta-subunit (bhCG). This is available from 14–20 weeks (optimal at 15–16 weeks) with results available 2 weeks after the test. High bhCG, low AFP and low oestriol are associated with Down’s syndrome. Falsepositives occur in around 5%. A ‘positive’ result is defined as a risk of greater than 1 in 250. In these cases amniocentesis or chorionic villus sampling is offered. A finding of raised AFP alone is associated with a break in fetal skin often indicating neural tube defects such as spina bifida and anencephaly. As there is a large overlap with the normal and abnormal levels of AFP, further testing is needed for firm diagnosis such as a scan for spina bifida. This is the most appropriate test for this woman as due to her young age she has an inherently low risk of carrying a fetus affected by Down’s syndrome and it is a non-invasive test. Fetal echocardiography is used for women with a high risk of fetal cardiac abnormalities and is done in the second trimester. Indications are women with congenital heart disease, diabetes or epilepsy, those with a previous child with congenital heart disease or abnormal or inadequate views of the heart at routine second trimester scans or a high risk nuchal translucency result. This has no role in the screening for Down’s syndrome although affected babies are at increased risk of cardiac abnormalities. Practice

Answer 6

A – Dizygotic dichorionic diamniotic Dizygotic twins are the most common type of twins (60%). They develop due to fertilization of two different ova, from the same or opposite ovaries, by two different sperm so are not identical. They can be of different sexes and are no more genetically similar than siblings would be. They implant separately into the decidua and have their own circulation. They are always dichorionic and diamniotic which means each fetus has its own chorion, amnion and placenta. Placental tissue may appear continuous due to close implantation sites but there will be no significant vascular communications. Chorionicity is best determined by ultrasound in the first trimester. Dichorionic twins have widely separated first trimester sacs or clearly separate placentae and a dividing membrane thicker than 2 mm.

Answer 7

D – Myomectomy Following dysfunctional uterine bleeding, uterine pathology is the next most common cause for menorrhagia. Pathology can be benign such as uterine fibroids, endometrial polyps, adenomyosis or pelvic infection, or it is rarely malignant such as endometrial cancer. Fibroids are benign tumours of myometrium containing whorls of smooth muscle cells with collagen. They are largely asymptomatic and are present in 20% of women of reproductive age, more commonly in Afro-Caribbean and nulliparous women. Presentation depends on the size and location of fibroids as they vary widely in size; some are microscopic and others have been known to be 40 kg! They can be intramural (within the uterine wall), subserous (beneath the serosal surface of the uterus) or submucosal (beneath the mucosal surface of the uterus). The most common presentation of fibroids is menorrhagia with intermenstrual bleeding and abdominal swelling. Pressure on the bladder from a large anterior fibroid can lead to frequency of micturition or to hydronephrosis due to ureteric compression. Other presenting features may be infertility, miscarriage, dyspareunia or pelvic discomfort. Treatment is not required if fibroids are asymptomatic. Medical treatment for menorrhagia associated with fibroids includes progesterone tablets and gonadotrophinreleasing hormone analogues. Surgical options include a myomectomy either abdominally, laparoscopically or hysteroscopically, or a hysterectomy. Myomectomy allows conservation of a patient’s fertility. This is either an abdominal or a laparoscopic procedure. The pseudocapsule of the fibroid is incised, the bulk of the tumour is enucleated and the resulting defect is sealed. Risks of this procedure include uncontrolled bleeding requiring hysterectomy, recurrence of fibroids and adhesion formation leading to reduced fertility. Hysteroscopic resection is not an option in this case as they are not submucosal.

Answer 8

D – Erythromycin Preterm pre-labour rupture of membranes (PPROM) is where the membranes rupture without contractions before 37 weeks and occurs in 2–3% of pregnancies. The woman describes a gush of fluid per vagina associated with a continuous trickle subsequently. Diagnosis is made on sterile speculum examination to visualize the amniotic fluid draining from the cervical os, and the patient is asked to cough during examination to elicit a gush of fluid from the cervix. A vaginal swab, urine specimen and liquor specimen are taken to test for infection. A digital examination should not be performed due to the risk of introducing infection. Other investigations that may help in diagnosis are the nitrazine test which measures the pH of the vagina. Amniotic fluid is more alkaline than normal vaginal secretions, however there are false-positives with blood, urine, semen or antiseptic cleaning agents. An ultrasound may be performed to check for reduced liquor if there is a convincing history but no liquor seen on examination. If pre-labour rupture of membranes occurs at term the majority of women labour within 24–48 hours and if this does not occur naturally they are augmented. However if rupture of membranes occurs preterm the risks of continuing the pregnancy such as maternal and fetal infections have to be weighed up against the risks of prematurity, therefore the management is usually conservative before 34 weeks and the woman is monitored for any signs of impending infection. Monitoring includes regular temperature and pulse, daily CTG, twice-weekly blood tests for white cell count and CRP and weekly or twoweekly ultrasound scans. Outpatient management can be used where the patient monitors her temperature at home and attends for daily CTG and other tests needed. Concerning features suggesting imminent infection or chorioamnionitis include maternal pyrexia, high white cell count or CRP, foul smelling liquor or meconium, uterine tenderness or fetal tachycardia.

Answer 9

A – No – combination of age and hypertension The combination of age over 35 and hypertension is considered too much of a risk of arterial disease to safely prescribe the combined oral contraceptive pill (COCP).

Answer 10

C – Spermatid

Answer 11

C – Group B streptococcus Up to one-quarter of women have vaginal colonization by group B streptococcus (GBS) at some stage of pregnancy. Infection is asymptomatic to the mother so it is detected using culture of vaginal swabs which are taken opportunistically when a mother is to be examined for any reason. GBS is associated with preterm rupture of membranes and neonatal sepsis. Fifty percent of babies born to GBSpositive women will become colonized during vaginal delivery but only about 1% develop infection. Neonatal GBS sepsis causes 1 in 65 of all neonatal deaths. If it is picked up on routine swabs, the woman should deliver on an obstetric unit so antibiotics can be given in labour to reduce neonatal infection. Antibiotics should be given if GBS is detected incidentally in the vagina or urine in the current pregnancy or if a woman has had a previous baby with neonatal GBS infection. There is no need for antibiotics if GBS was detected in the previous pregnancy with no ill effects to the baby. There is no need for antibiotics if the woman is having a Caesarean section. Intravenous penicillin G is the antibiotic of choice, given as soon as possible after the onset of labour and at least 2 hours before delivery. There is no national screening programme for GBS as initial positive results may become negative without treatment. Also there is no evidence for antenatal treatment as infection may quickly return following treatment

Answer 12

D – Total hysterectomy This patient is clearly distressed and requires more than just medical treatment. If this had been simple menorrhagia without the complication of the CIN II then she could have been treated with endometrial ablation or hysterectomy either total or subtotal. However, in patients with CIN II, it is recommended that if there are other reasons for a hysterectomy to be performed then hysterectomy can be considered as a treatment for CIN, in effect to ‘kill two birds with one stone’. The patient must still be followed up with vault smears due to the increased risk of vaginal intraepithelial neoplasia. A hysterectomy is the only treatment that will ensure amenorrhoea. Obviously in this case a total hysterectomy, which removes the uterus and cervix, would be performed otherwise this would not treat the CIN. This could be undertaken vaginally or abdominally. A total hysterectomy with bilateral salpingo-oophorectomy also removes (ectomy) the tubes (salpingo) and ovaries (oophor). The uterus alone is removed in a subtotal hysterectomy and the tubes, ovaries and cervix are retained. Risks of hysterectomy include bleeding, infection, pain, damage to bowel and urinary tracts, postoperative thromboembolism and vaginal prolapse in later life. Subtotal hysterectomies tend to be quicker with less risk of damage to the urinary tract and bowel

Answer 13

C – Placental abruption Placental abruption describes separation of the placenta from the uterus prior to third stage of labour. Mild abruption, where there is minimal separation, may present with little pain or bleeding and with minimal consequence to fetus or mother. Major abruptions present with sudden-onset constant, sharp, severe low abdominal or back pain, maternal shock and variable amounts of vaginal bleeding. The uterus is irritable and tender and may become hard due to tonic contraction. The tense uterus means it is difficult to palpate fetal parts and there is often loss of fetal movements. Intrauterine death from hypoxia is common unless action is taken. The clinical condition of the mother and degree of shock may not correlate well with the amount of blood loss seen vaginally as bleeding can be contained behind the placenta (concealed abruption). In this case the epidural was effective for the level of pain from contractions but the increased level of pain from the abruption was such that it was registered by the mother despite the epidural. Delivery must be expedited and in this case a Caesarean section is required. If the cervix had been fully dilated an instrumental delivery could have been considered. Risk factors for abruption are hypertension, pre-eclampsia, sudden decompression after membrane rupture in polyhydramnios or multiple pregnancies, previous abruption (10% recurrence), trauma to the abdomen and tobacco or cocaine abuse although the cause is unknown in many cases. The incidence is 0.5–2%.

Answer 14

E – Prostaglandin inhibitors This girl is suffering from menorrhagia (heavy cyclical menstrual bleeding over several consecutive cycles) and primary dysmenorrhoea (excessively painful periods). The first-line treatment is with non-steroidal anti-inflammatory drugs (NSAIDs), e.g. mefanamic acid or ibuprofen. NSAIDs act as prostaglandin synthesis inhibitors to reduce pain and also reduce blood loss by up to 25%. Side-effects are mainly gastrointestinal. If this does not provide sufficient relief of symptoms, further options can be considered. Antifibrinolytics (e.g. tranexamic acid) inhibit the breakdown of a formed clot. These are only to be taken during the heavy days of menstruation. Menstrual loss is reduced due to increased clot formation in the spiral arteries by reducing fibrinolytic activity by inhibiting plasminogen activator. For this reason they must not be used by women with predisposition to thromboembolism. This can reduce blood loss by 50%. The combined oral contraceptive pill (COCP) can reduce the amount of pain and bleeding by 50% experienced during menstruation. It can also regulate periods if there is an erratic cycle. This has to be discussed sensitively as it is a form of contraception and there can be issues with using contraception. Progestogens can reduce bleeding and also act as contraception. They are useful if the patient is not suitable for the COCP due to contraindications such as weight, age and smoking habits. Gonadotrophin-releasing hormone (GnRH) analogues are not first-line treatments for menorrhagia or dysmenorrhoea. They are used in dysmenorrhoea caused by endometriosis or can be used to shrink fibroids prior to definitive treatment. GnRH analogues cause amenorrhoea by down-regulating the pituitary hormones, leading to inhibition of ovarian activity. There are consequences of the hypoestrogenic state (similar to menopause) including hot flushes and vaginal dryness. Loss of bone mineral density is also a problem with use over 6 months therefore they should only be used short-term or with add-back therapy such as tibolone (a synthetic steroid often used as hormone replacement therapy).

Answer 15

D – Magnesium sulphate Clinical features of pre-eclampsia in addition to raised blood pressure (BP) are headaches, visual disturbances, restlessness or agitation, fluid retention with reduced urine output, epigastric pain, vomiting, hyperreflexia or signs of clonus (signs of cerebral irritability), papilloedema, retinal oedema or haemorrhages, liver tenderness, low platelets ,100106/L, abnormal liver enzymes or any signs of HELLP syndrome. However, there may be no signs before convulsions occur. If a woman develops severe pre-eclampsia she must have regular observations of BP, urine, bloods and strict fluid balance. Bloods include FBC, U & E, uric acid, LFTs, albumin and coagulation. The fetus should also be monitored using CTG or USS as indicated. Severe pre-eclampsia is defined as systolic BP 170 mmHg on two occasions or diastolic BP 100 mmHg on two occasions together with significant proteinuria of over 1 g/L on a 24-hour collection. Managing seizures Prophylactic administration of magnesium sulphate is used for a woman at ris of convulsions and is continued 24 hours after delivery or 24 hours after the last fit. Fluid balance, reflexes, respiratory rate and oxygen saturation must be monitored. A convulsion is an obstetric emergency and the full team should be involved. Firstly call for help and summon the senior obstetrician, senior midwife and anaesthetist. Resuscitation should be initiated as with any person who is convulsing by firstly checking it is safe for you to approach, limiting injury to the patient and then initiating management with ABC. The woman should be placed in the left lateral position to avoid aortocaval compression and to keep the airway open. An airway should be used if needed and high flow oxygen should be administered. After a convulsion, provided the CTG is reassuring, the baby should be delivered once the mother’s condition is stable and the appropriate people are present. Delivery should not be performed if it is not safe to do so as the mother’s life has priority over the baby. Magnesium sulphate is also used for treatment of fits in pregnancy.

Answer 16

A – Atosiban Premature labour is labour before 37 weeks. Labour is suggested by the presence of painful regular contractions associated with cervical change although there may just be some lower abdominal pain or silent dilation of the cervix. Tocolytics inhibit smooth muscle in the uterus to delay rather than stop labour to allow time for steroids to take effect and allow transfer of the mother to a hospital that has adequate facilities for neonatal resuscitation if needed. They are only given for 48 hours as this is how long the steroids need to work. Absolute contraindications are maternal condition requiring immediate delivery, intrauterine infection, fetal compromise, lethal fetal congenital abnormality or fetal death. Relative contraindications include fetal growth restriction, pre-eclampsia or significant vaginal bleeding. Atosiban works by competitive inhibition of oxytocin and binds to myometrial receptors causing an inhibition of intracellular calcium release leading to muscle relaxation. There are minimal maternal side-effects but it is very expensive. Beta-sympathomimetics stimulate b-receptors (some are b2 selective) on myometrial cell membranes to reduce intracellular calcium levels and therefore inhibit the actin–myosin interaction that would normally lead to uterine smooth muscle contraction. It is given as an intravenous infusion. They are becoming less popular due to the high number of side-effects which include tachycardia, hyperkalaemia, skin flushing, nausea, vomiting, visual disturbances and hyperglycaemia. More severe consequences such as hypotension, pulmonary oedema, severe maternal bradycardia and other arrhythmias have been seen and even maternal death. Due to these side-effects it is important to be sure of the diagnosis before administering these. Examples are ritodrine, terbutaline and salbutamol.

Answer 17

D – Oestradiol Oestradiol is a steroid hormone and is mainly secreted by the ovary. Levels of oestrogen and progesterone are low during the initial stages of the follicular phase due to the regression of the corpus luteum from the previous cycle. Primary follicles develop in the ovary under the influence of follicle-stimulating hormone (FSH) and leuteinizing hormone (LH) and this causes the level of oestrogen to rise due to increased production by the granulosa cells of these developing follicles. The increased level of oestrogen leads to negative feedback to produce a decline in LH and FSH concentrations. The level of oestrogen reaches its peak 18 hours prior to ovulation and this very high level of oestrogen is thought to be responsible for the mid-cycle surge in LH (positive feedback) which initiates ovulation. Immediately prior to ovulation, oestrogen levels fall and there is a rise in progesterone production. After ovulation the corpus luteum is formed from the remainder of the follicle, and this is the main source of oestrogen and progesterone post-ovulation. Oestrogen and progesterone are maintained at a high level for the luteal phase and only fall when the corpus luteum degenerates and the next cycle starts. Therefore during menses levels of oestrogen are low. If conception and implantation occur the corpus luteum is maintained by gonadotrophin released by the trophoblast. The latter half of the follicular phase of menstrual cycle correlates to the proliferative phase of the endometrium. The high concentration of oestrogen seen at this time promotes rapid regeneration of the endometrium that has been shed during the recent menses. It stimulates proliferation of glandular and stromal elements of the endometrium to give tubular glands arranged in a regular pattern, parallel to each other with little secretion. Oestrogen also stimulates production of increased amounts of thin, clear, stringy cervical mucus which is easily penetrable by sperm; a feature known as ‘spinnbarkeit’.

Answer 18

D – Give postnatal anti-D

Answer 19

C – Inevitable miscarriage This scenario describes an inevitable miscarriage where there is cramping abdominal pain, vaginal bleeding and dilation of the cervical os. The fetus may still be alive, but miscarriage will occur. It is important to counsel women appropriately when they have had recurrent miscarriages. This woman will have had 3 consecutive miscarriages but as long as she does not have any specific recurring cause she still has a 60–75% chance of a successful pregnancy. However, because she has had 3 consecutive miscarriages she should be investigated. There are a number of reasons why miscarriages may happen; however, 50% of miscarriages, both sporadic and recurrent, have no identifiable cause. Fetal chromosomal abnormalities are seen in half of the first trimester miscarriages including autosomal trisomy (50%), polyploidy (20%) and 45XO (20%). This incidence decreases to 20% with second trimester miscarriages. Endocrine factors include polycystic ovarian syndrome and poorly controlled diabetes. Immunological causes include autoimmune disease and alloimmune disease. Uterine anomalies may contribute to miscarriages such as bicornuate or septae uteri and fibroids. Infection in the mother during pregnancy can lead to poor outcome for the fetus. Specific infections such as rubella and cytomegalovirus can cross the placenta and cause miscarriage.

Answer 20

D – Teratoma The presentation is of torsion of an ovarian cyst and the operation findings suggest a teratoma. Germ cell tumours are all very different from each other. They include dysgerminoma, endodermal sinus or yolk sac tumour, choriocarcinoma and teratoma. These are more commonly seen in young women and children. They comprise 20–25% of ovarian tumours but only 4% are malignant. Teratoma (dermoid cyst) is a common benign cyst which contains elements of all three embryonic germ cell layers. Teratomas are thought to occur when the ovum develops without fertilization, known as parthenogenesis. They are generally seen in women in their 20s. Epithelium, hair and even teeth can be found in mature teratomas. They are usually small, bilateral and often asymptomatic, but do cause pain if there is torsion or rupture. Malignant change is rare (,1%) and is generally seen in squamous cells, in postmenopausal women. They can be hormonally active and secrete hCG, a-fetoprotein and thyroxine. Endodermal sinus or yolk sac tumour is the second most common malignant germ cell tumour of the ovary. The median age of onset is 19 years and it is rarely seen over 40 years. Patients present with sudden onset pelvic symptoms and a pelvic mass. There is a normal hCG but increased a-fetoprotein serum levels. Twenty percent of patients have coexistent teratomas. Dysgerminomas are the most common malignant germ cell tumour and the most common ovarian malignancy found in young women with 75% occurring in women aged 10 to 30 years. It is the most commonly seen ovarian malignancy in pregnancy. Ten percent are bilateral. There may be an increased serum hCG level. Sex cord/stromal tumours are rare and represent only 5% of all ovarian tumours. These include granulosa cell tumours, thecomas, fibromas and Sertoli/Leydig cell tumours. Granulosa cell tumours are usually slow-growing malignant tumours. They commonly secrete sex hormones primarily oestrogen which can, depending on age of presentation, lead to precocious pseudopuberty, irregular menstrual bleeding or postmenopausal bleeding. This is useful when screening for recurrence using serum oestradiol levels. On histological examination, the pathognomonic ‘gland like’ spaces, Call–Exner bodies and ‘coffee bean’ nuclei are seen. Fibroma tumours contain fibroblastic-type cells and are rarely malignant. Fibromas may present with non-malignant ascites and pleural effusion which resolve after removal of tumour (Meigs’ syndrome).

Answer 21

D – Monozygotic dichorionic diamniotic Monozygotic dichorionic diamniotic twins occur if division occurs at less than 3 days after fertilization (8-cell stage). The two embryos can implant at separate sites and each has a separate chorion, amnion and placenta. They will have the same structural appearance in utero as dizygotic twins but will be identical twins.

Answer 22

D – Mucinous tumour Investigations for pelvic masses include blood tests for routine haematological and biochemical measurements and tumour markers. Tumour markers are useful in diagnosis, response to treatment and recurrence. Eighty percent of malignant ovarian masses have an increased CA-125 although a raised CA- 125 may also be seen with peritoneal trauma and a normal CA-125 does not rule out cancer. Around 65% of ovarian germ cell tumours have an increased serum hCG, a-fetoprotein or both. An ultrasound or CT is useful to look for benign explanations for the pelvic mass such as simple ovarian cysts and uterine fibroids and will also assess spread to some extent. Malignant cysts tend to have a solid appearance, a thickened cyst wall, presence of septae within the cyst, bleeding within cyst and bilateral cysts. A chest X-ray is needed to rule out pulmonary metastases and to look for pleural effusions. Disease extent is only fully confirmed by laparotomy and biopsy at the time of definitive surgery. Ovarian cancer is staged as follows: Stage 1 Disease macroscopically confined to ovaries Stage 2 Disease is beyond ovaries, but confined to pelvis Stage 3 Disease is beyond pelvis, but confined to abdomen Stage 4 Disease is beyond the abdomen

Answer 23

E – Human papillomavirus 16 and 18 Cervical cancer is the second most common malignancy in women in the world. The two peaks of diagnosis are 35–39 years and 60–64 years. There are a small number of women who are diagnosed with early cervical cancer from smear tests however the vast majority of women diagnosed with invasive carcinoma have never had screening. Most (80%) are symptomatic, and presentation can be with abnormal per vagina bleeding (postcoital, intermenstrual or postmenopausal) or a chronic vaginal discharge (purulent, blood-stained, watery, mucoid or malodorous). Late disease is often indicated by pain including backache or referred leg pain, leg oedema, altered bowel habit, haematuria, malaise and weight loss. Human papillomavirus (HPV) is a sexually transmitted DNA virus of which there are over 80 types. There is a strong association between HPV serotypes 16, 18 and 33 and pre-invasive and invasive cervical cancer. HPV is thought to act by producing proteins E6 and E7 which influence the action of the p53 tumour suppression gene. There is a vaccine for HPV (Gardasil) which is licensed for both males and females between 9 and 15 years, and females between 16 and 25 years. Three injections of Gardasil are given at 0, 2 and 6 months and immunity lasts for at least 5 years. Immunocompromised patients may still be re-infected despite a completed course. It is hoped that using the vaccine will reduce cervical and vulval dysplasia and genital warts. Currently about one-third of all women in their 20s carry the HPV.

Answer 24

B – Ectopic pregnancy The most likely diagnosis in this patient is an ectopic pregnancy despite the patient having no pain, as with a bhCG result of 2365 iu a gestational sac should have been visualized if it were intrauterine. A laparoscopy should be considered to look for the ectopic fetus. If the result of the bhCG had been lower than 1000 iu and no gestational sac had been seen, the bhCG should be rechecked in 48 hours to assess whether it was doubling, reaching a plateau or falling.

Answer 25

C – Hysteroscopy and endometrial biopsy This woman is at high risk of endometrial cancer and should be urgently referred for hysteroscopy and endometrial biopsy, the gold standard for investigation. This can be done as an outpatient procedure or under general anaesthetic if the woman prefers or if there are other medical problems. Dilation and curettage used to be the gold standard but is now known to miss 10% of endometrial cancers. This is performed under general anaesthetic Endometrial biopsy can be performed at an outpatient clinic via a Pipelle or Vabra aspirator. The Pipelle biopsy only samples 4% of the endometrial surface and will miss one-third of tumours. The Vabra device picks up more tumours as it samples around 40% of endometrial surface but is more painful and more expensive. Endometrial biopsy alone should only be used for patients with very low risk of carcinoma due to the low pick-up rates. At first presentation it is acceptable to take a Pipelle biopsy as long as the patient is also referred by fast track for hysteroscopy with endometrial biopsy. If the Pipelle biopsy shows malignancy then hysteroscopy will be avoided and referral can be made straight to gynaecology oncology for staging. Transvaginal ultrasound is used to measure the thickness of the endometrium in postmenopausal women. Endometrial cancer is unlikely if thickness is less than 4 mm. Malignancy is much more likely if fluid is seen in the endometrial cavity. Ultrasound can be used as a non-invasive screening test, especially if surgical measures are not tolerated.

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O&G #2 Flashcards

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