Women's Health Final Exam

Management of LSIL

-A result of LSIL is a good indicator of HPV infection, recent metaanalysis showed prevalence of 76.6%.1 -Prevalence of CIN 2 or greater found at initial colposcopy is 12 - 16%. -Data from ALTS show the risk of CIN 2,3 is the same in women with LSIL and with ASC-US who are positive for HR HPV, and should be managed in the same way except in special populations. -In the current guideline management of this result is heavily dependent on age

Colposcopy

-Colposcopy is a confirmatory, diagnostic (not screening) examination -Clean cervix with saline, note any visible lesions, leukoplakia -Generous and repeated application3-5% Acetic acid. Squamous cells with relatively large or dense nuclei reflect light and turn white. Blood vessels and columnar cells become easier to see. Better differentiation of the transformation zone. -Areas of white epithelium are examined for abnornaml vascular patterns, such as punctuation, mosaicism, or atypical vessels

Indications for intrapartum transfer

-Malpresentation: breech, transverse lie identified during labor -Preeclampsia -Chorioamnionnitis -Fetal intolerance of labor when birth is not imminent or in presence of meconium -Need for pharmacologic augmentation of labor -Signs of placental abruption or unexplained increased vaginal bleeding -Cord prolapse -Management of lacerations beyond the expertise of the attending midwife -Postpartum hemorrhage unresponsive to initial treatments -Retained placenta -Unexplained vaginal bleeding -Uterine rupture, uterine inversion -Unstable health status of newborn

Current pregnancy contraindications

-PTL or PPROM -Essential or gestational hypertension -Fetal anomalies requiring immediate management -Fetal growth restriction <5th percentile -GDM requiring pharmacologic management -Malpresentation: breech, transverse lie -Need for pharmacologic induction of labor -Postterm pregnancy more than 41 6/7 weeks -Multiple gestation -Oligohydramnios, polyhydramnios -Placenta previa in the third trimester -Placental abruption -Preeclampsia -Rh isoimmunization

Management of ASC-H

-Prevalence of CIN 2,3 is higher in women this result than those with ASCUS. 24-94% with this result will have HSIL compared with on 5-17% of women w/ASCUS. -ASC-H is consider equivocal HSIL until colposcopy suggests otherwise (in women of any age).

What are the goals of pap screening?

-Prevent morbidity and mortality from cervical cancer -Prevent overzealous management of lesions that most likely will regress or disappear and for which the risks of management outweigh the benefits

Prior OB contraindications to out-of-hospital birth

-Previous stillbirth or neonatal death related to intrapartum event -Severe postpartum hemorrhage -Prior cesarean birth -Shoulder dystocia with resulting injury

Management of atypical glandular cells

-Relatively uncommon result, reporting rate only 0.4%. -Though occurs rarely, when found it is commonly associated with significant underlying neoplastic conditions including adenocarcinomas of cervix, endometrium, ovary, and fallopian tube. -Because of the wide spectrum of neoplasias possible and the low sensitivity of individual testing modalities, multiple approaches are needed. -Colposcopy with ECC is recommended for all women with AGC as initial treatment except for those with atypical endometrial cells. Those women should be evaluated first with Endometrial biopsy and ECC. Endometrial bx is also done in all women over 35 and women younger than 35 with unexplained bleeding or chronic anovulation.

What are some PMH contraindications for out-of-hospital birth?

-Serious medical conditions, including: cardiac disease, epilepsy, thromboembolic disease, hemoglobinopathy, renal disease, IDDM -Infections, including: hepatitis, HIV, HSV, syphilis, TB -Psychiatric conditions requiring hospital management -Substance abuse/dependence

Management of HSIL

-This finding carries a high risk for significant cervical disease. A single colposcopy will reveal CIN2 or greater in 53-66% of women. CIN 2 or greater is found in 84-97% of women evaluated with excisional procedure. -As colposcopy can miss a significant number of lesions, most women with this result will have an excisional procedure at some point. -As there is considerable risk for CIN 2 or greater, triage with repeat cytology of HPV reflex is never acceptable (in women of any age).

Management of ASC-US

-This finding of ASC is least reproducible of all results, and prevalence of invasive cancer in women with ASC is very low (0.1-0.2%). -In the current algorithms the management of this is heavily dependent on age. -Reflex testing (HPV testing) eliminates need for women to return the office, assures women they do not have significant lesions, and spares 40-60% of women from colposcopy. Reflex testing or screening is avoided in women under 25. If reflex testing shows no HPV, we can screen again in 3 years. Otherwise repeat in 12 months.

What are questions we ask about when evaluating for anemia?

1. S/S of anemia 2. Hx of bleeding, Hx of anemia with pregnancy, closely spaced pregnancy 3. Family history of hemoglobinopathy 4. Counsel to take iron and folic acid 5. Counsel to take vitamin C

Chorionic villi sampling

10+ weeks Generally used in 1st trimester. Results in 7-10 days.

Deaths from cervical cancer

12,000 new cases per year, 4,000 deaths Most cases occur between 35 and 55

Amniocentesis

15+ weeks Generally used in 2nd trimester. Results in 14 days.

Quad screen

15-20 weeks. Tests for AFP, hCG, uE3, and inhibin. Risk calculated based on GA, weight, diabetes, ethnicity.

Anatomy ultrasound

18-20 weeks

How much more calories do people need during pregnancy?

350-450 calories/day

What do we give for pain relief before endocervical curettage?

600-800 mg ibuprofen for cramping

Iron deficiency anemia

75-95% of all anemias diagnosed in pregnancy. Caused by depletion of body's Fe stores, decreased Fe intake.

What are variant hemoglobin types?

A - normal adult hemoglobin E-hemoglobin E C - Hemoglobin C F - Fetal Hemoglobin S - Sickle hemoglobin

CIN 3

A high grade lesion (very atypical) but includes full-thickness lesions.

Vitamin B12 deficiency anemia

A macrocytic anemia. Seen with strict vegetarians who do not drink milk. Inadequate production of intrinsic factor-post gastrectomy or pernicious anemia. Malabsorption syndrome. Laboratory findings are similar to folic acid deficiency except, serum B12 is low and folate level is normal.

LAST Terminology

A project that tried to use LSIL and HSIL to describe histological results in addition to cytological results. LSIL: CIN 1 HSIL: CIN 2/3 There was not enough evidence to use this new terminology. It was proposed because the distinction between CIN 2 and CIN 3 is often poor.

Endocervical curettage

A way to biopsy the cervix

What are treatments for high grade cervical disease?

Ablative treatments (cryotherapy) Excisional treatments (laser conization, loop electrosurgical excision, cold knife conization)

What are causes of normocytic anemia?

Acute blood loss Hemolytic disorders: Hemoglobin S disease* Hemoglobin C disorders Spherocytosis Glucose 6 Phosphate Dehydrogenase deficiency(G6PD)* Acquired anemia Aplastic anemia Chronic disease

What events happen when after HPV infection?

After 6 months, it can develop into a persistent infection or CIN 1. Between 5-9 years, we can get the development of CIN 2/3. After 9-15 years, we get the development of cervical cancer.

AGC

Atypical glandular cells (AGC), with attempts to identify whether the origin of the cells is endometrial, endocervical, or unspecified. "Endocervical adenocarcinoma in situ" and "AGC, favor neoplastic" are included as separate AGC categories.

ASC

Atypical squamous cells (ASC) divided into 2 categories: (1) ASC of "undetermined significance" (ASC-US) and (2) "cannot exclude high-grade squamous intraepithelial lesion" - ASC-H.

Where does the additional Fe go in pregnancy?

Average increased of 1000 mg with approximately: -500 mg related to expansion of maternal RBC mass -300 to fetus and placenta -180-200 mg loss thru various secretions-nl human loss (gut, urine & skin)

How much does blood increase in pregnancy?

Average plasma volume expansion of 50% by 34-36 weeks gestation. 30% increase in RBCs.

What is the lifetime prevalence of HPV infection?

Between 75-90% of men and women

How much have pap smears decreased deaths?

By over 50%

What is the percentage of CIN 2/3 that regresses?

CIN 2: 50-70% CIN 3: 20-30%

What are synonyms for low-grade disease?

Condyloma, mild dysplasia, LSIL, CIN 1, HPV infection

CIN 1

Considered a low grade lesion. Refers to mildly atypical cellular changes in lower 1/3 of epithelium.

What are some biological and psychosocial effects of group prenatal care?

Decreased preterm birth (especially in African American women), increased breastfeeding, increase care utilization, decreased STIs, increased pregnancy duration and birth weight, more adequate care Decreased depression, decreased stress, increased satisfaction with care, decreased pregnancy specific stress In general, women liked the community provided by these meetings.

What is the purpose of colposcopy?

Exclude the presence of invasive disease. Accurate interpretation of the colposcopic findings are central to the decision of whether and where to direct the biopsy.

What are symptoms of anemia?

Fatigue, drowsiness Malaise Sore tongue, glossitis Tachycardia Pale fingernail bed Loss of appetite N/V Dizziness, weakness Headaches Skin pallor and mucous Pica

Causes of microcytic anemia

Fe deficiency * Thalassemia* Hgb E & C disorders Sideroblastic anemia Gaucher's disease Chronic disease

CFF DNA

Fetal DNA in maternal plasma. Highly sensitive and specific for Trisomy 18, 21; sex determination. Offered to women at risk for aneuploidy.

What are consequences of excessive gestational weight gain?

Fetal macrosomia or LGA, cesarean birth, GDM, preeclampsia or gestational hypertension, childhood overweight or obesity

What are health consequences of anemia in pregnancy?

Fetus: IUGR, prematurity, IUFD, amnion rupture and infection Pregnant person: decreased energy, cardiovascular symptoms, decreased immune function, pp hemorrhage, peri-partum blood transfusion, increased risk of infection

What is a common cause of megaloblastic anemia?

Folate deficiency

What are dosages for nutritional supplements?

Folic acid: 0.4-1 mg QD Vitamin C: 250 mg QD

Normal types of hemoglobin in adult

Hemoglobin A (two alpha chains and two beta chains) - 95 to 98 percent Hemoglobin A2 (two alpha chains and two delta chains) - 2 to 3 percent Hemoglobin F (two alpha chains and two gamma chains) - Less than 2 percent

What hemoglobin values indicate anemia in pregnancy?

Hgb <10.5 (2nd trimester) or <11 (1st and 3rd trimesters)

What do we do if anemia does not improve?

Hgb falls to 9-10 g/dL, initiate further testing. Tests include: repeat CBC, serum iron, platelet count, total iron-binding capacity, peripheral blood smear, retic. count, serum ferritin, Hgb electrophoresis Hgb <9 g/dL. Consult with physician. Initiate previous lab work if not already done. Depending on GA, may need to give IM/IV Fe.

CIN 2

High grade cell changes in >2/3 of epithelial thickness but with preservation of epithelial maturation.

HSIL

High grade squamous intraepithelial lesion

What is the peak time for HPV infection?

Highest rate between 15 and 24 years. Many people are infected within their first two years of sexual activity.

What categories do we use for histology?

Historically, mild, moderate and severe dysplasia were the terms used. That language was then replaced by the CIN nomenclature. And we now an even newer nomenclature is proposed.

How to we do the second follow-up appointment for anemia?

If Hgb levels do not stabilize or drop below previous baseline: Reassessment -taking supp? How? With what? Tolerating? -Following diet? -Pica present? If unable to tolerate PO Fe, consider IM/IV Other causes include: GI issues like Crohn's, ulcerative colitis, Celiac, intestinal parasites, infection, kidney failure

How do we manage anemia at the initial appointment?

If hemoglobin <10.5: 1. Start on Fe, folic acid, and multi-vit supp 2. Counsel on Fe rich foods 3. Reticulocyte count in 2-3 weeks after woman has begun taking Fe. Retic count should increase, since body is responding to Fe

Why do we screen for HPV in older women?

In older women the prevalence of HPV decreases so a positive test is more likely to represent a persistent infection. Additionally, women with a negative HPV test are at even lower risk of having future CIN 3 than women who have a normal pap smear (better negative predictive value).

Bethesda Terminology

Includes specific statements about specimen adequacy and quality, category of result, and certain other findings. Includes ASC, LSIL, HSIL

How much iron and folate do people need in pregnancy?

Iron: 27 mg Folate: 0.4-0.6 mg

G6PD

Is the most common hereditary RBC deficiency, located on the X chromosome. Populations mostly affected: Africans, African Americans, Mediterranean, Sephardic Jews, Asiatic Jews & Asians. Results in hemolysis of RBC's with exposure to certain foods (fava beans) or medications: Nitrofurantoin Sulfamethoxazole Primaquine

Can HPV become latent?

Lots of evidence shows many people go to state where HPV appears to be fully cleared - sensitive DNA testing is negative Best answer: we cannot be sure if an infection is new or reactivated - new infections are common, especially in young women; but reactivated infections also seem to occur - particularly in older and immune-comprised patients.

LSIL

Low grade squamous intraepithelial lesion

CBC with indices and Fe studies

MCV>/= 80 fl; no significant Haemoglobinopathy MCV<80fl; do SI, TIBC, ferritin, %Fe sat, Hgb elec. --if % Fe sat>15, Hgb C or Hgb E present; diagnosis Hgb C/E dx or trait; counsel --if % Fe sat>15, HbA2 </=3.5%; eval relatives; dx A-thal; counsel; partner eval

What does lab work look like in folate deficiency anemia?

Macrocytic, normochromic cells Hypersegmented polymorphonuclear leukocytes Nl or low retic count Decreased RBC folate < 165ug/dl, serum folate < 6 mg liter B12 level is normal

Causes of macrocytic anemia

Megaloblastic: Nutritional deficiency* GI Malabsorption disorders* Primary bone marrow disease HIV, Sz and methotrexate Rxs Non megaloblastic: Hypothyroid Hepatic disease splenectomy

What are some things that can contribute to anemia in pregnancy?

Menstrual blood loss, nutritional deficiencies, diets high in phytates can leech Fe in the gut, increased demands of the fetus, parasitic/infectious disease

What are Fe needs during the childbearing years?

Menstruating women need 15-20 mg Fe/day to compensate for avg. daily loss of 2 mg Pregnant women need approximately 27mg Fe/day

Who gets cervical cancer?

Most is found in women who have never been screened. Some cases occur in people not screened five years prior. Many are false negatives. It is more common in ethnic minorities or non-US born women.

What are we really concerned about if we see it?

Persistent oncogenic HPV infection, CIN 3, CIN 2 in older women, persistent CIN 2/3 in adolescents and younger women

Cryotherapy

Probe against the cervix. Cells damaged by freezing are shed over the next month in a heavy watery discharge. Cryo simple and inexpensive. Cervix often heals with the SCJ inside the canal of the cervix - can make future evaluation more difficult. Cryo acceptable treatment for small, completely visualized areas of dysplasia, but has a high failure rate for treating large areas of dysplasia and dysplasia that extends into the cervical canal. Failure rate is higher.

What factors influence normal hemoglobin levels?

Race: black women have lower hemoglobin Smokers: higher lower limits of hemoglobin Living in high altitudes Increase in maternal plasma volume causing dilutional anemia

Histology

Refers to interpretation of tissue samples obtained from colposcopy guided biopsy.

LEEP

Replaced previously used cone technique. Both diagnosis and treatment. Fine wire loop with electrical energy to remove the abnormal area of the cervix, which is sent for biopsy. When indicated, may be an excellent treatment method, but should be used only for lesions with malignant potential. Has implications for outcomes in future pregnancies.

Cervical scaring and stenosis

Risk correlates with size of excision and also menopausal status. Stenotic cervix can interfere with future visualization of T-zone and increase difficulty of office procedures (e.g. endo bx, IUC insertion, IUI) - Not well studied.

What are consequences of inadequate weight gain?

SGA, PTB, perinatal mortality, failure to initiate breastfeeding

What kind of carrier screen should be done on all women?

SMA, CF, CBC

Folate deficiency anemia

Serum folate levels 5-12. Alcohol abuse interferes with metabolism of folate. The most common macrocytic anemia of pregnancy.

What are synonyms for high-grade disease?

Severe dysplasia, HSIL, CIN 2/3, pre-cancer, carcinoma in situ

What foods should people avoid in pregnancy?

Soft cheeses, raw dough, deep sea fishes, raw fish, unpasteurized juice, unpasteurized milk, salads made in the store, raw shellfish, raw or undercooked sprouts, cold cuts, undercooked eggs, eggnog, fish, ice cream, undercooked meats, meat spread, smoked salmon

What is a genetic cause of normoblastic anemia?

Thalassemia

Squamocolumnar Junction

The cervix is covered by both columnar and squamous epithelium. The SCJ, where these two meet, is the most important cytologic and colposcopic landmark, as this is where over 90% of lower genital tract neoplasia arises.

What should be done with initial testing for someone with anemia?

The initial evaluation of a pregnant person with moderate anemia should include measurements of hemoglobin, hematocrit, and red cell indices; careful examination of a peripheral blood smear; a sickle-cell preparation if the person is of African origin; and measurement of serum iron or ferritin levels, or both.

Nuchal translucency

Ultrasound at 11-14 weeks that tests for trisomy 18, 21, and cardiac issues. Usually combined with 1st trimester traditional serum markers.

What is recommended weight gain?

Underweight: 28-40 Normal weight: 25-35 Overweight: 15-25 Obese: 11-20

Cytology

We look at cytology because the cells at the surface are a marker of the tissue underneath.

What is the current opinion on whether or not low grade lesions will develop into cancerous lesions?

With the discovery that most CIN1 and CIN2 lesions regress or persist unchanged, the question has been raised as to whether high-grade CIN might be a process that develops concurrently with low-grade CIN. This theory is supported by the fact that CIN3 can develop without a detectable preceding low-grade CIN lesion, and high-grade CIN is almost always found closer to the SCJ than concomitant low-grade lesions. Schiffman, et al. reported that both CIN1 and CIN2,3 lesions developed within the same time frame in a large group of women who turned HPV positive and were followed for 4 years. Currently, most experts believe CIN1 has minimal potential for progression to cancer and simply reflects underlying HPV infection, while CIN2,3 is of indeterminate malignant potential. CIN3 is considered a true cancer precursor.