Uterine Neoplasms Flashcards
What is the most common pelvic tumor in women
Leiomyomas (fibroids)
Define: estrogen dependent smooth muscle tumor that is slow growing
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
What is the cc of a pt with leiomyomas
Bleeding
Mass effect
What is the 1st step in the evaluation of a Fibroid (Leiomyoma)
U/S
What are two tx for leiomyomas (fibroids) that can be done for pts that want to preserve pregnancy
Myomectomy: preserves fertility, but, firboids may recur
Uterine artery embolization (“uterine fibroid embolization”) preserves fertility, but higher risk of placental complications
Define: nests of endometrial glands and stroma embedded with in the muscular uterine wall
Adenomyosis
Present w/ heavy abnormal uterine bleeding or dysmenorrhea in parous women 40-50
Basically endometriosis within the myometrium
What is the first line eval for Adenomyosis
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
What is the approach to Endometrial Hyperplasia
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)
What is the greatest risk of Cancer with Endometrial Hyperplasia
Nuclear atypia type
Greatest: complex hyperplasia w/ atypia
Least: simple hyperplasia w/out atypia
What is the approach to Endometrial Hyperplasia with Atypia
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)
What is the approach to Endometrial Hyoperplpasia without atypia
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)
A pt presents with vaginal bleeding, pelvic pressure, bloating, and early satiety
Think
Endometrial cancer
Premenopausal women: prolonged heavy menstruation or intermenstrual spotting
Postmenopausal women (5-10% chance of cancer)
What is Lynch Syndrome
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
What is required for Dx of Endometrial Cancer
EMbx
What is required to make a Dx of Endometrial Cancer
Endometrial Bx
Any woman over 45, with AUB =
Endometrial Bx
Or, if < 45, but RF (obesity, PCOS, failed medical mgt of AUB, etc): EMB!
Is serum marker CA125, Dx for Ca ‘?
No, its for surveillance not for dx of cancer
What is the Tx for endometrial Cancer
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
What is the threshold for functional cysts
3 cm or bigger in a reproductive age woman
What is the most common ovarian neoplasm
Germ Cell Neoplasm
(Rapid Growing)
Aka Teratoma
What is the role of CA125 in ovarian mass evaluation
CA-125 may help in postmenopausal patients
Simple cyst that is larger than 7 cm in a post menopausal cyst
What is the approach
MRI/ Surgical Eval!
What is the approach to NON simple cysts
Premenopausal: Repeat TVUS in 6/12 weeks, all else: consider surgery eval (refer)
Which side is more likely to have ovarian torsion
R side
L side more limited by sigmoid colon
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
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
What is the primary driving hormone in PCOS
LH (elevated)
What are the ovarian causes of Hyperandrogenemia
Neoplasm
Or PCOS!
What is the androgen and estrogen levels in PCOS
HIGH in both
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)
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
- RULE OUT NEOPLASM!!
- Look for functional d/o
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)
A pt presents with Acanthosis nigricans, virilization, with luteinized theca cells
Think
Ovarian Hyperthecosis (Severe PCOS)
Treat same as PCOS
HyperAndrogenic+Insulin Resistant+Acanthosis Nigricans
Think
PCOS Variant (HAIRAN)
Average age of Ovarian Cancer Dx
Early 60s
Is there an effective screening test for Ovarian Cancer
No
What is the most common cases/etiology of ovarian cancer
Epithelial Ovarian Carcinomas
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
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
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
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
CA 125 and ovarian cancer
Not useful marker to detect ovarian cancer
Good to follow during & after treatment
More useful in post-menopausal patient
A pt presents with ascites and a pelvic mass.. .think
Ovarian cancer!
No masses → consider liver disease or GI/pancreatic cancer
What is the most useful initial image for Ovarian Cancer
US and then a follow up CT to determine planning for advanced Dz
After US for ovarian cancer
What is the next step
CT Abdomnen/ Pelvis
How is ovarian cancer staged
Surgically staged
Define Embryo
Conceptus from time of fertilization to 8 weeks (10 wks Gestational Age)
Define fetus
> 8 weeks (>10 weeks Gestational Age) until birth
Define Periviable birth
Delivery occurring from 20+0/7 to 25+6/7
Define preterm
Infant delivered 24-37 weeks
Born prior to the 37th completed week (<259 days)
Example: 36+5/7 EGA
Define Full term
Infant delivered 37 through 41+6/7 weeks
259-293 days
Define Post term
Delivered ≥42 weeks
294 days or more
Define Abortion
Pregnancy losses
Fetus weighs <500 g OR
Occurs prior to 20 completed weeks EGA
No chance of survival
A pt that presents with painless hemorrhage in the 3rd trimester
Placenta Previa
What are the RSK factors for abruptio placentae
Chronic HTN
And preeclampsia
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
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
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
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”
What is the most accurate way to determine age in the 1st trimester
US
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
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
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
When is HIV screening done for pregnancy
All women at new OB; repeat 3rd trimester for high risk
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)
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
Hutchinson teeth, mulberry molars, saddle nose/ frontal bossing, and saber shins
Think
Syphillis in pregnancy
Treat with penicillin
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)
Do you vax for Rubella while the pt is pregnant
NO!
Screen for rubella in pregnant women
IgG titer ( 4 fold)
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
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)
Hep B screen in pregnancy
HBsAg and rescreen in 3rd trimester
What is the risk of Hep B
Cirrhosis and Cancer (Liver)
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
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)
What is the number 1 cause of neonatal sepsis in the US
Group B strep
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
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
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
Pregnant pt with pyelonephro
ADMIT!
When do you administer Tdap (pertussis)
27-36 wk
When do you admin rubella
MMR (measles, mumps, rubella) administer postpartum
breastfeeding not contraindicated
What is the auto/air travel advice for pregnancy
AAP/ACOG: can safely travel up to 36 wks
Exercise in pregnancy recommendation
Encourage regular, moderate-intensity physical activity at least 150 mins/wk
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
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
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.
Coffee advise in pregnancy
500mg or more increased risk of miscarriage
Less than 200 no real risk
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
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
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
S./s of mass effect in the Uterus
Urinary frequency
Incontinence
Constipation
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
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
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
Which can get bigger, fibroids or adenomyomas?
Fibroids can look bigger than 12 weeks gestation
Adeno- rarely that big
What is the classic Tx for adenomyosis
Hysterectomy
A woman with AUB IMB with hyper plastic overgrowth of the endometrium on a stalk …
Endometrial polyps
Get TVUS -> recommended removal-> usually hysterectomy
What is the hormone responsible for endometrial hyperplasia
Estrogen
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
Is TVUS good for looking at endometrial hyperplasia in premenopausal women ?
Not reliable
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
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
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
what is the general appraoch to non simple cyst in women
Premenopausal: Repeat TVUS in 6/12 weeks, all else: consider surgery eval (refer)
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
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
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
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
What separates placenta previa from placenta abruptio
Abruptio is PAINFULLLLLL!
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
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)
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
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
When do we screen for GBS
35-57 weeks
Screening strategy for GPS (strep agalactiae)
Screen with vaginal swab at 35 -37 weeks
Treat all women with +GBS cultures
What is the general approach to vaccines in pregnancy
Most of the LIVE vaccines are contraindicated whereas most of the TOXOID vaccines are indicated!
When do we screen for domestic violence in pregnant women
At 1st visit , then once per trimester and then again at post partum visit
How much should women be screened for depression and BH in pregnancy
At least once
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
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)
Crown rump length less than _____ = fetal demise
Less than 5 mm
