OB_Gynecologic_Tumours - Gynecologic Tumors Gynecologic...

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Unformatted text preview: Gynecologic Tumors Gynecologic Tumors With Pregnancy Prof. Dr. Mohamed Samir Fouad Professor OBGYN Al­Azhar University President www.arabicobgyn.net Leiomyoma Leiomyoma About 1% in pregnant women It is formed of fibers and muscle of uterus and can be submucous, interstitial, or subserous Fibroid with Pregnancy Fibroid with Pregnancy Effect on Pregnancy * Abortion… increase with submucous * Incarceration of RVF gravid uterus (posterior wall) * Ectopic pregnancy if pressing on the tube * Preterm labor * Pressure symptoms …increase size of uterus above expected date Large abdominal tumor may cause abdominal discomfort, dyspnea, palpitation Pelvic tumor may increase pressure on bladder, rectum and pelvic veins *Malpresentation * non­engagement of presenting part * Placenta Praevia due to interference with implantation of fertilized ovum in the upper segment * Acute abdomen ...­Red degeneration ­torsion of pedunculated subserous fibroid ­hemorrhage from ruptured surface vein Fibroid with Pregnancy Fibroid with Pregnancy Effect on Labor Uterine Atony… due to mechanical interference with uterine contractions : ­ Prolonged labor ­ retained placenta ­ Postpartum Hemorrhage Submucous fibroid increase incidence of placenta accreta and retained placenta Obstructed labor: ­ cervical fibroid ­subserous fibroid impacted in the pelvis below the presenting part Fibroid with pregnancy Fibroid with pregnancy Effect on Puerperium * Subinvolution * Secondary Post partum hemorrhage (submucous or fibroid polyp) * Inversion of the uterus may be caused by fundal submucous fibroid * Increased incidence of puerperal sepsis due to infection of traumatized tumor and interference with drainage of uterus Effect of pregnancy on Fibroid Increase size of fibroid due to hypertrophy and increased vascularity Softness of the tumor due to interstitial edema….flattening of fibroid and may become indistinct Subserous tumor may be readily palpated as the uterus enlarges and on occasion may be mistaken for fetal parts Submucous and fibroid polyp are more prone to infection specially in puerperium and after abortion Red degeneration is common leading to subacute or acute abdomen Torsion of pedunculated subserous fibroid is common in puerperium when there is rapid involution of uterus and laxity of abdominal wall leading to increased mobility of intra­abdominal organs Management Management Follow­up Red degeneration with abdominal pain: ­bed rest ­reassurance ­analgesics Torsion of subserous fibroid: surgery and removal of the stalk with fibroid …no other interferences Caeserean section if fibroid causing obstruction to labor ..no interference with fibroid to avoid excessive bleeding and re­ evaluate after 6 weeks Caeserean hysterectomy may be indicated wit multiple fibroids in patient competed her family Cancer cervix and Pregnancy Cancer cervix and Pregnancy The incidence of CIN varies but it is generally between 1% to 8% of abnormal cytology. Invasive cancer is the most common solid tumor during pregnancy Fortunately its incidence is 0.2% to0.9% of all pregnancies..1.4% of all cases of cancer cervix Cancer Cx. with pregnancy Cancer Cx. with pregnancy Symptoms Usually asymptomatic, detected during routine Pap smear Vaginal bleeding and discharge may be mistaken for pregnancy .complications Pelvic pain..less frequent Cervical Screening During Cervical Screening During Pregnancy Cervical cancer peaks between age 30 to 49 years The mean age of pregnant women with invasive cervical cancer 31.8y. Significant numbers diagnosed in 2nd or 3rd trimester Efficacy and safety of screening is well­ documented Diagnosis during pregnancy Diagnosis during pregnancy Colposcopy is safe and well tolerated and should be used to evaluate abnormal Pap smear Any suspicious lesion should be biopsed the overall risk of biopsy­related complications is approximately 0.6% usually mild bleeding . Diagnosis during pregnancy Diagnosis during pregnancy .((cont Cervical conization during pregnancy..crucial in diagnosis and staging of MIC. Complications…Hemorrhage 2­13% Fetal loss 17%­50%, <10% in 2nd,3rd *PMRM *Preterm labor *infection, laceration and stenosis * Fetal Salvage89­95% Workup during pregnancy Workup during pregnancy Physical examination cervical biopsy conization chest x­ray with abdominal shield since about 83% of cases are stage I cystoscopy and proctoscopy are eliminated.also I.V.U and Enema. Treatment of CIN during Treatment of CIN during pregnancy No indications for immediate treatment of cases with CIN during pregnancy Pap smear and colposcopy every trimester Vaginal Delivery with higher rate of regression at 6­ week examination compared to Caesarean delivery Definitive treatment…6 weeks postpartum Treatment of invasive cancer Treatment of invasive cancer during pregnancy Invasive cancer during pregnancy is curable Treatment is clear in the 1st and 3rd trimester but less clear in the 2nd trimester the two modalities used are surgery or Radiotherapy as in non­pregnant (T.T during pregnancy (cont T.T during pregnancy (cont First trimester(1­12weeks) Fetal salvage is not feasible in women receiving treatment for invasive cancer The maternal risk from delaying therapy until fetal maturity is excessive Surgery with the fetus in situ (T.T during pregnancy (cont T.T during pregnancy (cont Second trimester (13­25weeks) The period of greater uncertainty Fetal salvage is exceedingly rare with high neonatal mortality rate Delaying therapy for several weeks may subject the mother to the theoretical risk of disease progression Summary of t.t Delays Summary of t.t Delays Author N. Stage Delays outcome Monk et al 3 IB (1992 ( Mean 24 wk DOD Duggan e t 8 IA-IB al (1993 ( Mean NED 20 . 6 w Sorosky 8I et al (1996 Mean NED 15 . 6 w T.T 2nd trimester T.T 2nd trimester If patient elects to interrupt pregnancy.. The same as in 1st trimester If not ..define a target gestational age for fetal delivery Monitor by U/S..and MRI for tumor extension Documented lung maturity 3rd trimester Treatment Wait for few weeks till fetal maturity then apply definitive therapy Surgery in 89% may be coordinated with fetal delivery and completed as a 1­stage operation. If R.T..external beam immediately after delivery followed by intracavitary radiation Effect of Mode of Delivery Effect of Mode of Delivery Aut hor C.S % su r viv al Creasman 9 89 % et al( 1970) Lee et al 12 90 % ( 1981) Nisker et al 14 64 % ( 1983) Van Der 28 78 % Vang et al ( 1995) vaginal % su r vi val 15 87 % 11 89 % 17 65 % 16 67 % Ovarian tumors with pregnancy Ovarian tumors with pregnancy Incidence 1:1000 pregnancy Benign tumors are common e.g. luteal cyst and Dermoid cyst Malignant tumors 5% ­Ovarian malignancy has no effect on pregnancy and pregnancy has no effect on prognosis of ovarian cancer ­Benign cyst may undergo torsion causing acute abdomen commonly in puerperium Ovarian Tumors with pregnancy Ovarian Tumors with pregnancy Management of benign tumor First trimester….observe and follow­up with ultrasound till second trimester (to reduce risk of abortion) and then removal through laparotomy Second trimester….laparotomy Third trimester.. Caesarean section and removal of tumor Malignant tumors …treated as non­pregnant i.e. surgical staging and cytoreductive surgery ...
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