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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
A pt presents with low grade fever, N/V, and lower abdominal pain What is the ddx
Torsion (low grade fever suggests necrosis) (can start off intermittently) ectopic pregnancy, tuboovarian abscess, hemorrhagic ovarian cyst, & endometrioma
26
What is the primary problem of PCOS
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
27
What is the primary driving hormone in PCOS
LH (elevated)
28
What are the ovarian causes of Hyperandrogenemia
Neoplasm Or PCOS!
29
What is the androgen and estrogen levels in PCOS
HIGH in both
30
What are the 3 criteria to Dx PCOS
Hyperandrogenism -Either clinical signs or lab evidence Chronic oligo/anovulation Rule out other diagnoses +/- Polycysts (note required)
31
What is the w/u for PCOS
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
32
Tx approach to PCOS
``` 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)
33
A pt presents with Acanthosis nigricans, virilization, with luteinized theca cells Think
``` Ovarian Hyperthecosis (Severe PCOS) ``` Treat same as PCOS
34
HyperAndrogenic+Insulin Resistant+Acanthosis Nigricans Think
PCOS Variant (HAIRAN)
35
Average age of Ovarian Cancer Dx
Early 60s
36
Is there an effective screening test for Ovarian Cancer
No
37
What is the most common cases/etiology of ovarian cancer
Epithelial Ovarian Carcinomas
38
Rsk Fx for Endometrial Cancer
Obesity PCOS Long term High dose unopposed estrogen Early Menarche Late Menopause Infertily Nulliparious North American High education level White and Old DM
39
What are the Rsk Fx for Ovarian Cancer
Nulliparity Early Menarche Late Menopause Old and WHite North American Fam HX Hx of breast cancer !! Post menopausal hormone therapy Pelvic inflammatory Dz
40
What is a protective factor for Ovarian cancer
Breast feeding!! Long term OCPS (Reduce risk by 50%) Tubal Ligation/ Hysterectomy (prevents irritants from getting to ovaries) Healthy Diet
41
Ovarian Cancer and BRCA Genes
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
42
CA 125 and ovarian cancer
Not useful marker to detect ovarian cancer Good to follow during & after treatment More useful in post-menopausal patient
43
A pt presents with ascites and a pelvic mass.. .think
Ovarian cancer! No masses → consider liver disease or GI/pancreatic cancer
44
What is the most useful initial image for Ovarian Cancer
US and then a follow up CT to determine planning for advanced Dz
45
After US for ovarian cancer What is the next step
CT Abdomnen/ Pelvis
46
How is ovarian cancer staged
Surgically staged
47
Define Embryo
Conceptus from time of fertilization to 8 weeks (10 wks Gestational Age)
48
Define fetus
> 8 weeks (>10 weeks Gestational Age) until birth
49
Define Periviable birth
Delivery occurring from 20+0/7 to 25+6/7
50
Define preterm
Infant delivered 24-37 weeks Born prior to the 37th completed week (<259 days) Example: 36+5/7 EGA
51
Define Full term
Infant delivered 37 through 41+6/7 weeks 259-293 days
52
Define Post term
Delivered ≥42 weeks | 294 days or more
53
Define Abortion
Pregnancy losses Fetus weighs <500 g OR Occurs prior to 20 completed weeks EGA No chance of survival
54
A pt that presents with painless hemorrhage in the 3rd trimester
Placenta Previa
55
What are the RSK factors for abruptio placentae
Chronic HTN And preeclampsia
56
What is velamentous placenta
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
What is Vasa Previa
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
What is Gestational age
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
When should women have their 1st OB pregnancy appointment
“New OB appointment”: ~10-12 wks gestation Often preceded or associated w/ group orientation class: “Centering Pregnancy”
60
What is the most accurate way to determine age in the 1st trimester
US
61
What is the obstetric conjugate?
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
What is Naegeles Rule
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
On US what is the most accurate predictor of Gestational Age
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
When is HIV screening done for pregnancy
All women at new OB; repeat 3rd trimester for high risk
65
What is the Tx for HIV pos. pregnancy
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
When is toxoplasmosis a risk to pregnancy And what is the tx
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
Hutchinson teeth, mulberry molars, saddle nose/ frontal bossing, and saber shins Think
Syphillis in pregnancy Treat with penicillin
68
Tx for syphillis in pregnancy
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
Do you vax for Rubella while the pt is pregnant
NO!
70
Screen for rubella in pregnant women
IgG titer ( 4 fold)
71
Most common congenital viral infection of pregnancy
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
When is the greatest opportunity for HSV transmission
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
Hep B screen in pregnancy
HBsAg and rescreen in 3rd trimester
74
What is the risk of Hep B
Cirrhosis and Cancer (Liver)
75
Treatment for Hep B in pregnancy
Newborns of HBsAg+ mothers: HBIG + Hep B vaccine w/in 12 hrs of birth - Prevents 95% of transmission - Mothers may breastfeed
76
Tx for Gon/ Chlaymdia in pregnancy
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
What is the number 1 cause of neonatal sepsis in the US
Group B strep
78
Tx for Group B strep in pregnancy
Colonized women should be treated w/ IV penicillin G (PCN allergic: clindamycin) -during labor to prevent strep in birth canal during labor
79
Risk factor strategy for treating Group B strep
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
Empiric treat for Bacteriuria
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
Pregnant pt with pyelonephro
ADMIT!
82
When do you administer Tdap (pertussis)
27-36 wk
83
When do you admin rubella
MMR (measles, mumps, rubella) administer postpartum | breastfeeding not contraindicated
84
What is the auto/air travel advice for pregnancy
AAP/ACOG: can safely travel up to 36 wks
85
Exercise in pregnancy recommendation
Encourage regular, moderate-intensity physical activity at least 150 mins/wk
86
Seafood in pregnancy
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
When should women start prenatal vitamins
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
What is the effect of accutane on fetal development
Bilateral microtia or anotia with stenosis of external ear canal. Flat, depressed nasal bridge and ocular hypertelorism.
89
Coffee advise in pregnancy
500mg or more increased risk of miscarriage Less than 200 no real risk
90
Why do we do dental exams on pregnant women
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
A Ct scans safe in pregnancy
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
What does PALM COEIN MEAN
Polys Adenomyona (estrongen dependent) Leiomyoma (estrogen Depednent) Malignancy and Hyperplasia (estrogen Dependent) ``` Coagulopathy Ovarian dysfunction Endometrial Iatrogenic Not yet classified ```
93
S./s of mass effect in the Uterus
Urinary frequency Incontinence Constipation
94
What is the treatments for Leiomyomas that can preserve pregnancy and what are the ones that will not
Myomectomy and Uterine artery emobilization (more complications) can preserve Endometrial ablation and Hysterectomy will not
95
Indications for Surgical intervention in a woman with fibroids
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
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
Fibroids/ Lieomyomas
97
Which can get bigger, fibroids or adenomyomas?
Fibroids can look bigger than 12 weeks gestation Adeno- rarely that big
98
What is the classic Tx for adenomyosis
Hysterectomy
99
A woman with AUB IMB with hyper plastic overgrowth of the endometrium on a stalk …
Endometrial polyps Get TVUS -> recommended removal-> usually hysterectomy
100
What is the hormone responsible for endometrial hyperplasia
Estrogen
101
What is the 1st step in Dx Endometrail Hyperplasia in POST menopausal women
TVUS, look at endometrial stripe thickness.. <4 = low risk of cancer >4= Bx for cancer
102
Is TVUS good for looking at endometrial hyperplasia in premenopausal women ?
Not reliable
103
What are the primary Treatment options for endometrial cancer
Hysterectomy w/ bilateral salpingo-oophorectomy (BSO) & lymph node staging Advanced disease: chemo, radiotherapy or both as adjuncts
104
What is normal endometrial stripe thickness
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
A simple Cyst in a post menopausal woman 1-5 cm gets what w/u
Ca125 level, if NML then repeat TVS in 6-12 weeks, if persistent cyst then TVS yearly
106
what is the general appraoch to non simple cyst in women
Premenopausal: Repeat TVUS in 6/12 weeks, all else: consider surgery eval (refer)
107
LABS in Ovarian Cancer W/u
CBC: thrombocytosis → 20-25% will have >400 Hyponatremia → 125-130 mEq/L (common finding) CA-125 Human epididymal protein 4 (HE4) tumor marker
108
What is the treatment for Ovarian Cancer
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
What is the prognosis for ovarian cancer than is in Situ, regional, or metz
Localized 5 year survival of 92 percent Regional: 72 percent Distant….. 27 percent
110
A hemorrhagic cyst in the early post menopausal stage gets what work up?
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
What separates placenta previa from placenta abruptio
Abruptio is PAINFULLLLLL!
112
What is the scheduling for uncomplicated OB visits
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
What is the prognosis for a HIV baby
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
What is the threshold to Dx Toxoplasmosis
Maternal antibody testing (IgM or 4x↑ IgG) Serologic testing of amniotic fluid or fetal blood Culture from placenta
115
If a pt is allergic to PCN but has syphillis what do we do ?
Desensitize and treat with penicillin! It’s the only thing we got
116
When do we screen for GBS
35-57 weeks
117
Screening strategy for GPS (strep agalactiae)
Screen with vaginal swab at 35 -37 weeks Treat all women with +GBS cultures
118
What is the general approach to vaccines in pregnancy
Most of the LIVE vaccines are contraindicated whereas most of the TOXOID vaccines are indicated!
119
When do we screen for domestic violence in pregnant women
At 1st visit , then once per trimester and then again at post partum visit
120
How much should women be screened for depression and BH in pregnancy
At least once
121
When should elective delivery be done
Elective, is delivery without a medical indication Should not be done prior to 39 weeks Cesarean delivery on request not recommend
122
When conducting TVUS what can be seen at 5, 6, and 7 week marks
Gestational sac 5 w (1500 hCG) Fetal pole: 6w (5200 hCG) Cardiac motion: 7w (17500 hCG)
123
Crown rump length less than _____ = fetal demise
Less than 5 mm

Senoir 21-2 (77 decks)

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