Endometrial Cancer

Carcinoma arising from endometrial tissue

Symptoms
• Post menapusal bleeding
• Irregular perimenstrual bleeding
• Heavy irregualar bleeding
• Constitutional symptoms ( LOA, LOW, Anemic Sx)
• Blood stained vaginal discharge

Risk factors of Endometrica CA

• Age>50
• Family history/ previous breast Ca
• Historu of hereditary non polyposis colorectal ca ( life time risk 40-60%)
• Endometrial hyperplasia +atypia
• DM/HTN
• Unopposed action of estrogen

- Endogenous
+ Early menarche
+ Nulliparous
+ Chronic anovoulatory cycles (PCOS/Obese)
+ Late menopause
+ Granulose cell ovarian tumor
- Exogenous
+ Hormone therapy (combined with progesterone reduces endm hyperplasia and ca
+ On tamoxifan


Physical Examination
Normal or bulky uterus


Investigations
• Blood Ix
CA125 (monitoring and recuurence)
FBC
LFT
RP
• TVS (endometrial thickness and morphology)
• Endometrial sampling (pippele sampling)
• Hysteroscopy
• Endometrial biopsy
• D&C /hysteroscopically
• CT (pelvis, abdomen, chest)
• Cystoscopy (tro bladder involvement)


Pathology
• ¾ arising from fundus
• 15% lower uterine cavity

Histological types
• Endometroid (75%)
• Adenoacanthoma
• Adenosquamous CA
• Papillary serous
• Clear cell
• Carcinosarcoma (malignant mixed mullerian turmor)


FIGO classification of endometrial Cancer

• Stage 1(confined to uterus)
1A- limited to endometrium
1B- invades less than half of myometrium
1C- invades more than half of myometrium

• Stage 2 (tumor invades cervix)
2A- endocervical glandular involvement
2B- cervical stromal invasion

• Stage3( local or regional spread)
3A- involve serosa
3B- vaginal involvement
3C- mets to pelvic and para aortic nodes

• Stage4 ( distant spread, bladder and rectal involvemnt)


Spread
• Direct (cervix, vagina, fallopian tube, ovary
• Lymphatic (pelvic, para aortic LN)
• Hematogenous (lung, liver) rare


Grading (based on deffrenciation and presence of mitotic figures
• G1- wel differentiated ,scanthy mit fig
• G2- moderately differentiated
• G3- poorly differentiated , presence of malignant cells

Management

• Stage1 : TAHBSO with peritoneal washing for cytology
• Stage2: werthin type redical hysterectomy with B/l pelvic lymphadenectomy +- para aortic dissection.
• Stage3: surgical debulking or radiotherapy to shrink the tumor
• Stage4: systemic chemo OR hormonal therapy.

Adjuvant therapies
• Radiotherapy : if >stage2,
• Hormone: for recurrence and for women not fit for surgey ( progesterone or tamoxifen)

Follow up
• Physical exam every 3-6 monthly for 2 years
• Vaginal cytology 6 monthly for 2 year
• CXR annually
• CA 125

Forceps Delivery

INDICATIONS

Maternal :
- Delay in the second stage of labour 9 poor maternal effort)
- condtions where short second stage of labour is desirable eg preeclampsia, heard disease, respiratory problem
- Maternal exhaustion

Fetal :
- fetal distress
- delivery of the after coming head in breach delivery

Prerequisites for Forceps Delivery

A - Adequate Analgesia, appropriate positioning(lithotomy position)
B - Bladder catheterization
C - Cervix fully dilated and membranes ruptured/counsel the patient
D - Determine the position, station and pelvic adequacy
E - Episiotomy / Equipment (check for matching pairs)

Procedure

F - forceps (phantom application)

- Lt blade , LT hand, maternal Lt side pencil grip & vertical insertion with Rt thumb directing blade

- Rt blade , RT hand, maternal Rt side pencil grip & vertical insertion with Lt thumb directing blade
...
- Lock blades

Check application:
Post fontanelle 1cm above the plane of the shanks
Sagittal suture lies in the midline of the shanks /perpindicular to the plane of the shanks
The operator can not place more than a fingertip between the fenestration of the blade & the fetal head on either side

G – Gentle traction : applied with contraction & maternal expulsive efforts

H – Handle elevated: traction in the axis of the birth canal do not elevate handle to early

I – Incision: consider episiotomy if laceration imminent

J – Jaw: remove forceps when jaw is reachable or delivery assured

COMPLICATIONS
Maternal
- trauma to soft tissue :3rd/4th degree, double the risk compared to ventouse
- bleeding from lacerations
- trauma to urethra & bladder or fistula
- Pain 17% ventouse 11%

Fetal- bruising & laceration to the face- Injury to the fetal scalp
- cephalohematoma 9% Vent 25%- retinal hemorrhage 30% Vent 50%
- skull fracture- permanent nerve damage / Facial nerve

Indications and Contraindications of Forceps instead of Ventouse
Indications
- Face presentations
- Bleeding from fetal blood sampling site
- after comming head of breach
- delivery before 34 weeks

contraindications to a vaginal assisted delivery
- head not fully engaged- cervix not fully dilated