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Senoir 21-2 > Uterine Neoplasms > Flashcards

Uterine Neoplasms Flashcards

1
Q

What is the most common pelvic tumor in women

A

Leiomyomas (fibroids)

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2
Q

Define: estrogen dependent smooth muscle tumor that is slow growing

A

Leiomyoma (fibroid)

Tx with
COC (decrease bleeding)
LngIUD (decrease bleeding)

Myomectomy
(preserves fertility, but fibroids may recur)

Uterine artery embolization (“uterine fibroid embolization”) preserves fertility, but higher risk of placental complications

Endometrial ablation: eliminates fertility but will reduce bleeding

Definitive Tx: Hysterectomy

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3
Q

What is the cc of a pt with leiomyomas

A

Bleeding

Mass effect

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4
Q

What is the 1st step in the evaluation of a Fibroid (Leiomyoma)

A

U/S

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5
Q

What are two tx for leiomyomas (fibroids) that can be done for pts that want to preserve pregnancy

A

Myomectomy: preserves fertility, but, firboids may recur

Uterine artery embolization (“uterine fibroid embolization”) preserves fertility, but higher risk of placental complications

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6
Q

Define: nests of endometrial glands and stroma embedded with in the muscular uterine wall

A

Adenomyosis

Present w/ heavy abnormal uterine bleeding or dysmenorrhea in parous women 40-50

Basically endometriosis within the myometrium

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7
Q

What is the first line eval for Adenomyosis

A

Endometrial bx frequently non-diagnostic

TVUS ~ 83% sensitive, 85% specific → US as 1st study

Will show heterogenous echotexture, compared to fibromas which are distinct

If all other studies are equivocal.. get an MRI

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8
Q

What is the approach to Endometrial Hyperplasia

A

Common in post menopausal women
MC S/s metrorhaggia

Benign entity; however, most endometrial cancers arise from progression of histologically distinguishable hyperplastic lesions
(Cancer Rsk)

Tx: Bx (gold standard)

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9
Q

What is the greatest risk of Cancer with Endometrial Hyperplasia

A

Nuclear atypia type

Greatest: complex hyperplasia w/ atypia

Least: simple hyperplasia w/out atypia

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10
Q

What is the approach to Endometrial Hyperplasia with Atypia

A

Thickened endometrium greater than 4mm = Cancer risk

Start with EMbx

Postmenopausal/post-childbearing: hysterectomy & BSO

OR

Hormonal therapy
(progesterins with Endometrial Bx q3mon.) in premenopausal patients wanting to retain reproductive capabilities
(Long IUD or PO provera)

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11
Q

What is the approach to Endometrial Hyoperplpasia without atypia

A

Can spont,. Regress w/o tx

3-6 mo course of low-dose progestin therapy
(oral, injectable or IUD OR combined oral contraceptives w/ endometrial biopsy q3-6m)

If resolves, continue therapy regimen to maintain endometrial protection until menopause

If fails to resolve: ↑ progesterone dose or surgery (hysterectomy)

Postmenopausal women: CoC / progestin therapy w/ endometrial biopsy q3-6 mos (SAME AS ABOVE for premenopausal women)

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12
Q

A pt presents with vaginal bleeding, pelvic pressure, bloating, and early satiety

Think

A

Endometrial cancer

Premenopausal women: prolonged heavy menstruation or intermenstrual spotting

Postmenopausal women (5-10% chance of cancer)

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13
Q

What is Lynch Syndrome

A

Lynch syndrome, often called hereditary nonpolyposis colorectal cancer (HNPCC), is an inherited disorder that increases the risk of many types of cancer, particularly cancers of the colon (large intestine) and rectum, which are collectively referred to as colorectal cancer

If a pt has this, it is the only clue to screen for Endometrial Cancer and prophylactic hysterectomy due to increased cancer risk

Screen these pts starting at age 30 q1-2 years

Recommended prophylactic hysterectomy at age 40

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14
Q

What is required for Dx of Endometrial Cancer

A

EMbx

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15
Q

What is required to make a Dx of Endometrial Cancer

A

Endometrial Bx

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16
Q

Any woman over 45, with AUB =

A

Endometrial Bx

Or, if < 45, but RF (obesity, PCOS, failed medical mgt of AUB, etc): EMB!

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17
Q

Is serum marker CA125, Dx for Ca ‘?

A

No, its for surveillance not for dx of cancer

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18
Q

What is the Tx for endometrial Cancer

A

Hysterectomy with Bilateral Salipingoectomy

Responds to progestin, and tamoxifen

Fertility sparing treatment:

  • Diagnostic hysteroscopy, D&C sampling, & imaging to exclude deep myometrial invasion or extrauterine disease
  • hormonal Treatment
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19
Q

What is the threshold for functional cysts

A

3 cm or bigger in a reproductive age woman

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20
Q

What is the most common ovarian neoplasm

A

Germ Cell Neoplasm
(Rapid Growing)

Aka Teratoma

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21
Q

What is the role of CA125 in ovarian mass evaluation

A

CA-125 may help in postmenopausal patients

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22
Q

Simple cyst that is larger than 7 cm in a post menopausal cyst

What is the approach

A

MRI/ Surgical Eval!

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23
Q

What is the approach to NON simple cysts

A

Premenopausal: Repeat TVUS in 6/12 weeks, all else: consider surgery eval (refer)

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24
Q

Which side is more likely to have ovarian torsion

A

R side

L side more limited by sigmoid colon

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25
Q

A pt presents with low grade fever, N/V, and lower abdominal pain

What is the ddx

A

Torsion (low grade fever suggests necrosis) (can start off intermittently)

ectopic pregnancy, tuboovarian abscess, hemorrhagic ovarian cyst, & endometrioma

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26
Q

What is the primary problem of PCOS

A

Steroid hormones that cause “maleness”
-Dehydroepiandrosterone (DHEA)
Adrenal gland
Weak

-Androstenedione
Adrenal gland & ovary
Weak

-Testosterone
Adrenal gland, ovary & adipose tissue
Potent

-Dihydrotestosterone (DHT)
Hair follicles/genital skin
Most potent

All controlled by LH! Acts with FSH and theca cells -> cholesterol to testosterone to estrogen

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27
Q

What is the primary driving hormone in PCOS

A

LH (elevated)

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28
Q

What are the ovarian causes of Hyperandrogenemia

A

Neoplasm

Or PCOS!

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29
Q

What is the androgen and estrogen levels in PCOS

A

HIGH in both

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30
Q

What are the 3 criteria to Dx PCOS

A

Hyperandrogenism
-Either clinical signs or lab evidence

Chronic oligo/anovulation

Rule out other diagnoses
+/- Polycysts (note required)

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31
Q

What is the w/u for PCOS

A

LH, FSH, (LH>FSH 2;1)

TSH, (Thyroid) 
 T, (CAH) (<150) 
 PRL, (tumor? ) 
 DHEAS, (<700) 
 17-OH-P (CAH? ) 
Lipids, glucose, BMI, abd circ, BP
  1. RULE OUT NEOPLASM!!
  2. Look for functional d/o
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32
Q

Tx approach to PCOS

A 
Low dose OCPs 
(Decrease overal androgen production) 
(decrease hirsutism over a year) 
-Add other anti-androgenic agents after 6 months as needed (can take 6-12 months for full effect) based upon sx
-Spirinolactone 
-Flutamide 
-Finasteride 
(Slows hair growth)

-alt: progesterone only
Fertility: Clomiphene

Metformin for pts with insulin resistance (DM screening)
(and can increase ovulation)

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33
Q

A pt presents with Acanthosis nigricans, virilization, with luteinized theca cells

Think

A 
Ovarian Hyperthecosis 
(Severe PCOS)

Treat same as PCOS

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34
Q

HyperAndrogenic+Insulin Resistant+Acanthosis Nigricans

Think

A

PCOS Variant (HAIRAN)

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35
Q

Average age of Ovarian Cancer Dx

A

Early 60s

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36
Q

Is there an effective screening test for Ovarian Cancer

A

No

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37
Q

What is the most common cases/etiology of ovarian cancer

A

Epithelial Ovarian Carcinomas

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38
Q

Rsk Fx for Endometrial Cancer

A

Obesity

PCOS

Long term High dose unopposed estrogen

Early Menarche

Late Menopause

Infertily

Nulliparious

North American

High education level

White and Old

DM

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39
Q

What are the Rsk Fx for Ovarian Cancer

A

Nulliparity

Early Menarche

Late Menopause

Old and WHite

North American

Fam HX

Hx of breast cancer !!

Post menopausal hormone therapy

Pelvic inflammatory Dz

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40
Q

What is a protective factor for Ovarian cancer

A

Breast feeding!!

Long term OCPS
(Reduce risk by 50%)

Tubal Ligation/ Hysterectomy (prevents irritants from getting to ovaries)

Healthy Diet

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41
Q

Ovarian Cancer and BRCA Genes

A

In carriers, only way to directly prevent cancer formation:
-remove ovaries prophylactically (tubes & ovaries are healthy at time of removal)

May remove at completion of childbearing yrs or by age 40
-90% effective in preventing epithelial ovarian cancer

Also ↓ breast cancer risk in this population

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42
Q

CA 125 and ovarian cancer

A

Not useful marker to detect ovarian cancer

Good to follow during & after treatment

More useful in post-menopausal patient

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43
Q

A pt presents with ascites and a pelvic mass.. .think

A

Ovarian cancer!

No masses → consider liver disease or GI/pancreatic cancer

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44
Q

What is the most useful initial image for Ovarian Cancer

A

US and then a follow up CT to determine planning for advanced Dz

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45
Q

After US for ovarian cancer

What is the next step

A

CT Abdomnen/ Pelvis

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46
Q

How is ovarian cancer staged

A

Surgically staged

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47
Q

Define Embryo

A

Conceptus from time of fertilization to 8 weeks (10 wks Gestational Age)

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48
Q

Define fetus

A

> 8 weeks (>10 weeks Gestational Age) until birth

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49
Q

Define Periviable birth

A

Delivery occurring from 20+0/7 to 25+6/7

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50
Q

Define preterm

A

Infant delivered 24-37 weeks

Born prior to the 37th completed week (<259 days)

Example: 36+5/7 EGA

51
Q

Define Full term

A

Infant delivered 37 through 41+6/7 weeks

259-293 days

52
Q

Define Post term

A

Delivered ≥42 weeks

294 days or more

53
Q

Define Abortion

A

Pregnancy losses

Fetus weighs <500 g OR

Occurs prior to 20 completed weeks EGA

No chance of survival

54
Q

A pt that presents with painless hemorrhage in the 3rd trimester

A

Placenta Previa

55
Q

What are the RSK factors for abruptio placentae

A

Chronic HTN

And preeclampsia

56
Q

What is velamentous placenta

A

umbilical cord is inserted in adjoining membranes w/ umbilical vessels entering placenta separately;

“velamentous cord insertion”

Risk for antepartum hemorrhage and high perinatal mortality

Can impact fetal development

57
Q

What is Vasa Previa

A

umbilical vessels in chorion, not placenta

Can occur with velamentous cord insertion, or on its own

Exposed vessels cross cervix

Easily torn away from placenta

Fetal death d/t exsanguination can occur within minutes

Typically, c-section ~35-37w

58
Q

What is Gestational age

A

Normal duration of pregnancy = Gestational Age (GA): typically calculated as menstrual age (precedes conception);
EGA: estimated GA

From 1st day of last menstrual period (LMP) to birth:
~280 days
40 weeks

59
Q

When should women have their 1st OB pregnancy appointment

A

“New OB appointment”: ~10-12 wks gestation

Often preceded or associated w/ group orientation class: “Centering Pregnancy”

60
Q

What is the most accurate way to determine age in the 1st trimester

A

US

61
Q

What is the obstetric conjugate?

A

Obstetric conjugate = diagonal conjugate minus (-) 1.5-2 cm (should be ≥10 cm)

Obstetric conjugate is the actual space available to fetus at pelvic inlet

Smallest diameter through which fetal head will pass

62
Q

What is Naegeles Rule

A

1st day of LMP
Subtract 3 months
Add 7 days = EDD

LMP of 16 Jan 2021
Jan – 3 months = October
16d + 7d = 23rd
EDD = 23 October 2021

63
Q

On US what is the most accurate predictor of Gestational Age

A

Crown Rump Length

Greatest accuracy in 1st trimester
US & LMP dates should match, but…
May need to change date to correspond w/ US if:

<9 wks EGA: >5d difference in dates

9 to <14 wks EGA: >7d difference in dates

64
Q

When is HIV screening done for pregnancy

A

All women at new OB; repeat 3rd trimester for high risk

65
Q

What is the Tx for HIV pos. pregnancy

A

Pregnant HIV+ women should receive standard antiretroviral therapy to ↓ vertical transmission to 1-2%
(if viral load <1000, can opt for vaginal delivery)

C-section: to ↓ neonatal transmission if viral load >1000 copies/mL

Avoid breastfeeding (↑ risk 10-20% of transmission)

66
Q

When is toxoplasmosis a risk to pregnancy

And what is the tx

A

Severe fatal sequelae in the 1st trimester

Tx:
Spiramycin (does not cross placenta) → only works for maternal infection

Pyrimethamine-sulfadiazine w/ folinic acid → maternal & fetal infection

67
Q

Hutchinson teeth, mulberry molars, saddle nose/ frontal bossing, and saber shins

Think

A

Syphillis in pregnancy

Treat with penicillin

68
Q

Tx for syphillis in pregnancy

A

Benzathine penicillin G 2.4 million U IM x1, then 2nd dose 1 wk later

-Jarisch-Herxheimer reaction (febrile response w/in 24 hrs of treatment)
Contractions, maternal fever, ↓ fetal movement, fetal HR decelerations)

-Treatment: supportive (antipyretics, hydration & oxygen supplementation)

69
Q

Do you vax for Rubella while the pt is pregnant

A

NO!

70
Q

Screen for rubella in pregnant women

A

IgG titer ( 4 fold)

71
Q

Most common congenital viral infection of pregnancy

A

CMV

Present w/ mental handicap, developmental delay, vision or hearing problems in infancy

If “mononucleosis-like” illness or concern for fetal infx → serologic testing (problems: IgM present up to 2 yrs, 20% false neg)

Treatment: supportive (prevention: good hygiene & hand washing)

Nothing you can really do, just supportive care

72
Q

When is the greatest opportunity for HSV transmission

A

Primary infection in pregnancy (no maternal antibodies): greatest risk of transmission to fetus/newborn
50% vertical transmission rate in Vaginal delivery

TX; prevention

  • Thorough perineal exam at onset of labor
  • Prophylactic acyclovir starting 36 wks, if history of genital herpes

-C-section if active genital infection during labor (or prodromal sx)

73
Q

Hep B screen in pregnancy

A

HBsAg and rescreen in 3rd trimester

74
Q

What is the risk of Hep B

A

Cirrhosis and Cancer (Liver)

75
Q

Treatment for Hep B in pregnancy

A

Newborns of HBsAg+ mothers: HBIG + Hep B vaccine w/in 12 hrs of birth

  • Prevents 95% of transmission
  • Mothers may breastfeed
76
Q

Tx for Gon/ Chlaymdia in pregnancy

A

Chlamydia treatment during pregnancy:
-Amoxicillin 500 mg TID for 7 days or Azithromycin 1000 mg x1
Gonorrhea:
-Ceftriaxone 250mg IM or Cefixime 400mg PO dosing

Do not use Doxy
(TCN C/I in pregnancy)

77
Q

What is the number 1 cause of neonatal sepsis in the US

A

Group B strep

78
Q

Tx for Group B strep in pregnancy

A

Colonized women should be treated w/ IV penicillin G
(PCN allergic: clindamycin)
-during labor to prevent strep in birth canal during labor

79
Q

Risk factor strategy for treating Group B strep

A

Patients with GBS bacteriuria

Previous infant with perinatal GBS infection

Delivery ≤ 37 weeks

Intrapartum fever (38°C/100.4°F)

Prolonged rupture of membranes (≥18 hrs)

treat the above criteria for GBS with penicillin

80
Q

Empiric treat for Bacteriuria

A

Empiric antibiotics: nitrofurantoin, amoxicillin, ampicillin

Must perform test of cure (TOC) after antibiotics completed

Pyelonephritis requires hospitalization for IV therapy

All receive prophylaxis for remainder of pregnancy

81
Q

Pregnant pt with pyelonephro

A

ADMIT!

82
Q

When do you administer Tdap (pertussis)

A

27-36 wk

83
Q

When do you admin rubella

A

MMR (measles, mumps, rubella) administer postpartum

breastfeeding not contraindicated

84
Q

What is the auto/air travel advice for pregnancy

A

AAP/ACOG: can safely travel up to 36 wks

85
Q

Exercise in pregnancy recommendation

A

Encourage regular, moderate-intensity physical activity at least 150 mins/wk

86
Q

Seafood in pregnancy

A

OK to eat low-mercury fish/shell fish & important to get omega-3 fats & protein
-8-12 oz/wk

-Limit to 6 oz/wk: (“white” tuna/albacore)

If unknown mercury content (local catch): NTE 6 oz/wk

87
Q

When should women start prenatal vitamins

A

Best if pre-conception
(neural tube closure by 28 days)
USPSTF: 0.4-0.8 mg po daily (400 mcg-800 mcg)
-Ideally 12 wks prior to becoming pregnant

4mg daily if previous Hx or Comorbidities

88
Q

What is the effect of accutane on fetal development

A

Bilateral microtia or anotia with stenosis of external ear canal. Flat, depressed nasal bridge and ocular hypertelorism.

89
Q

Coffee advise in pregnancy

A

500mg or more increased risk of miscarriage

Less than 200 no real risk

90
Q

Why do we do dental exams on pregnant women

A

Periodontal disease linked to preterm labor
(prevention is key since treatment does not improve preterm labor occurrence)

Dental treatment & radiographs not contraindicated in pregnancy

91
Q

A Ct scans safe in pregnancy

A

CT scans expose fetus to small amounts of radiation

Do not withhold potentially life-saving studies

Most centers avoid iodinated contrast agents in pregnancy because of risk of neonatal hypothyroidism

92
Q

What does PALM COEIN MEAN

A

Polys

Adenomyona (estrongen dependent)
Leiomyoma (estrogen Depednent)

Malignancy and Hyperplasia (estrogen Dependent)

Coagulopathy 
Ovarian dysfunction 
Endometrial 
Iatrogenic 
Not yet classified
93
Q

S./s of mass effect in the Uterus

A

Urinary frequency

Incontinence

Constipation

94
Q

What is the treatments for Leiomyomas that can preserve pregnancy and what are the ones that will not

A

Myomectomy and Uterine artery emobilization (more complications)
can preserve

Endometrial ablation and Hysterectomy will not

95
Q

Indications for Surgical intervention in a woman with fibroids

A

Indications for surgical intervention:

  • Rapid enlargement
  • Severe pelvic pain or secondary dysmenorrhea
  • AUB w/ anemia
  • Urinary tract symptoms
  • Inability to evaluate adnexa (usually corresponds w/ fibroid ≥12 wk gestational size uterus)
  • Growth of fibroid after menopause
  • Infertility
96
Q

A pt presents with a round, rubbery, mass in the pelvis (woman) that appears on US as increase uterine size with irregular uterine shape
+ bleeding, urinary frequency, and constipation

Think

A

Fibroids/ Lieomyomas

97
Q

Which can get bigger, fibroids or adenomyomas?

A

Fibroids can look bigger than 12 weeks gestation

Adeno- rarely that big

98
Q

What is the classic Tx for adenomyosis

A

Hysterectomy

99
Q

A woman with AUB IMB with hyper plastic overgrowth of the endometrium on a stalk …

A

Endometrial polyps

Get TVUS -> recommended removal-> usually hysterectomy

100
Q

What is the hormone responsible for endometrial hyperplasia

A

Estrogen

101
Q

What is the 1st step in Dx Endometrail Hyperplasia in POST menopausal women

A

TVUS, look at endometrial stripe thickness..

<4 = low risk of cancer

> 4= Bx for cancer

102
Q

Is TVUS good for looking at endometrial hyperplasia in premenopausal women ?

A

Not reliable

103
Q

What are the primary Treatment options for endometrial cancer

A

Hysterectomy w/ bilateral salpingo-oophorectomy (BSO) & lymph node staging

Advanced disease: chemo, radiotherapy or both as adjuncts

104
Q

What is normal endometrial stripe thickness

A

Less than 4 mm post menopausal

Greater than 5= Bx for hyperplasia or Cancer

Caution in pre menopausal women as the endometrial thickness changes throughout the cycle

105
Q

A simple Cyst in a post menopausal woman 1-5 cm gets what w/u

A

Ca125 level, if NML then repeat TVS in 6-12 weeks, if persistent cyst then TVS yearly

106
Q

what is the general appraoch to non simple cyst in women

A

Premenopausal: Repeat TVUS in 6/12 weeks, all else: consider surgery eval (refer)

107
Q

LABS in Ovarian Cancer W/u

A

CBC: thrombocytosis → 20-25% will have >400
Hyponatremia → 125-130 mEq/L (common finding)
CA-125
Human epididymal protein 4 (HE4) tumor marker

108
Q

What is the treatment for Ovarian Cancer

A

Hysterectomy & BSO w/ lymph node evaluation, peritoneal fluid evaluation, thorough abdominal cavity evaluation, peritoneal scrapings/biopsy

May attempt fertility sparing if meets criteria
-Chemo

109
Q

What is the prognosis for ovarian cancer than is in Situ, regional, or metz

A

Localized 5 year survival of 92 percent

Regional: 72 percent

Distant….. 27 percent

110
Q

A hemorrhagic cyst in the early post menopausal stage gets what work up?

A

A hemorrhagic cyst of any size should get a CA125 level, if normal then repeat TVS in 6-12 weeks, if persistent then consider MRI/ SRGRY

If in late menopause: SRGRY

111
Q

What separates placenta previa from placenta abruptio

A

Abruptio is PAINFULLLLLL!

112
Q

What is the scheduling for uncomplicated OB visits

A

Uncomplicated 1st & 2nd trimester (until 28 wks): every 4 wks

Uncomplicated 28-36 wks: every 2 wks

Uncomplicated 36+ wks: every wk

Complicated pregnancies require more like twins may need 2-3x more

113
Q

What is the prognosis for a HIV baby

A

50% of infected infants progress to AIDS by 1 yo (avg survival: age 3)

Vertical transmission rate: 20-30% (may occur ante-, intra- or post-partum)

114
Q

What is the threshold to Dx Toxoplasmosis

A

Maternal antibody testing (IgM or 4x↑ IgG)
Serologic testing of amniotic fluid or fetal blood
Culture from placenta

115
Q

If a pt is allergic to PCN but has syphillis what do we do ?

A

Desensitize and treat with penicillin!

It’s the only thing we got

116
Q

When do we screen for GBS

A

35-57 weeks

117
Q

Screening strategy for GPS (strep agalactiae)

A

Screen with vaginal swab at 35 -37 weeks

Treat all women with +GBS cultures

118
Q

What is the general approach to vaccines in pregnancy

A

Most of the LIVE vaccines are contraindicated whereas most of the TOXOID vaccines are indicated!

119
Q

When do we screen for domestic violence in pregnant women

A

At 1st visit , then once per trimester and then again at post partum visit

120
Q

How much should women be screened for depression and BH in pregnancy

A

At least once

121
Q

When should elective delivery be done

A

Elective, is delivery without a medical indication

Should not be done prior to 39 weeks

Cesarean delivery on request not recommend

122
Q

When conducting TVUS what can be seen at 5, 6, and 7 week marks

A

Gestational sac 5 w (1500 hCG)
Fetal pole: 6w (5200 hCG)
Cardiac motion: 7w (17500 hCG)

123
Q

Crown rump length less than _____ = fetal demise

A

Less than 5 mm

Senoir 21-2 (77 decks)

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