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<div> <A HREF="id32.htm" TARGET="_top" TITLE="Features of chromosomal defects "><U><B><IMG BORDER="0" SRC="Symb075c00b700c800ffff00.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Features of chromosomal defects </B></U></A></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="Ultrasound of Fetal Biometrics and Growt"><U><B><IMG BORDER="0" SRC="Symb075c00b700c800ffff00.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ultrasound of Fetal Biometrics and Growth</B></U></A></div> <div> <A HREF="id28.htm" TARGET="_top" TITLE="FEMALE MASS"><U><B><IMG BORDER="0" SRC="Symb075c00b700c800ffff00.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">FEMALE MASS</B></U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE=" testicular feminization syndrome "><U><B><IMG BORDER="0" SRC="Symb075c00b700c800ffff00.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> testicular feminization syndrome </B></U></A></div> <div> <A HREF="id27.htm" 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BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>pearls4</I></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endometrioid tumors, with characteristic psammoma bodies, have the highest malignant potential </B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Majority are cystic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2-35 cm </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Better survival than serous cystadenocarcinoma </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">55% 5 year survival </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">40% 10 year survival</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These are uncommon ovarian </B><B>tumors</B><B> accounting for less than 5% of all ovarian neoplasms and 15% of ovarian carcinomas. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Its name is derived from the histologic similarity to endometrial carcinomas of the uterus. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">About 5-10% of cases are associated with endometriosis. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In addtion, 10% of patients have evidence of ovarian or ovarian-breast cancer syndrome. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These patients have mutations in the BRCA1 genes.</B></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1021" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#000099 > <tR> <tD VALIGN=CENTER HEIGHT= 47 WIDTH="234"><div> <B>TUMOR TYPE</B></div> </tD> <tD VALIGN=CENTER WIDTH="218"><div> <B>GROSS FEATURES</B></div> </tD> <tD VALIGN=CENTER WIDTH="549"><div> <B>MICROSCOPIC FEATURES</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 71 WIDTH="234"><div> <B>Endometrioid</B><B> adenofibromas/cystadenofibromas</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> Usually solid with small cysts</div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> Tubular glands histologically similar to endometrium, in different phases </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 87 WIDTH="234"><div> <B>Endometrioid</B><B> adenofibromas of borderline malignancy</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> Usually solid with small cysts</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="549"><div> Atypical glandular epithelium with appearance of low-grade adenocarcinoma but does not invade the stroma</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 101 WIDTH="234"><div> <B>Endometrioid</B><B> adenocarcinoma</B></div> </tD> <tD VALIGN=CENTER WIDTH="218"><div> Solid or cystic</div> </tD> <tD VALIGN=CENTER><NOBR><div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Similar to endometrial adenocarcinoma of the uterus with invasion </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Squamous metaplasia in 1/3 of cases</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">May have mucin secretion, usually in surface of the cells</div> </NOBR></tD> </tR> </TABLE></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The endometrioid adenocarcinoma has several histologic variants, mimicking other primary ovarian cancers.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The pathologist must sample the ovarian tumor thoroughly to excluded these possibilities.</div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1098" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#000066 > <tR> <tD VALIGN=CENTER HEIGHT= 48 WIDTH="371"><div> <B>HISTOLOGIC VARIANT</B></div> </tD> <tD VALIGN=CENTER WIDTH="712"><div> <B>DESCRIPTION</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 75 ><NOBR><div> <B>Resembling sex cord-stromal </B><B>tumors</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="712"><div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Small glands and solid tubular structures resembling Sertoli cells</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Adenofibromatous component,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> squamous differentiation, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or mucin favors endometrioid carcinoma</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 53 ><NOBR><div> <B>Resembling granulosa cell </B><B>tumors</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="712"><div> Epithelial islands and trabeculae with microfollicles and acini</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 44 ><NOBR><div> <B>Resembling Sertoli-Leydig cell </B><B>tumors</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="712"><div> With luteinized stromal cells</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 57 WIDTH="371"><div> <B>Extensive spindle cell component resembling malignant mixed mullerian </B><B>tumors</B><B> </B></div> </tD> <tD VALIGN=CENTER WIDTH="712"><div> Spindle cells merging with epithelial cells</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 47 WIDTH="371"><div> <B>Resembling yolk sac tumor</B></div> </tD> <tD VALIGN=CENTER WIDTH="712"><div> Areas of AFP positive yolk sac epithelial components.</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 66 ><NOBR><div> <B>Resembling metastatic adenocarcinomas</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="712"><div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most difficult area, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">especially with metastatic colon adenocarcinomas</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">May need immunohistochemical stains</div> </tD> </tR> </TABLE></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One potentially confusing association is 20% of these </B><B>tumors</B><B> may be associated with an endometrial adenocarcinoma of the uterus.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In the majority of these cases, both </B><B>tumors</B><B> usually represent synchronous or metachronous events. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">However, findings that may favor a primary endometrial adenocarcinoma of the uterus metastasizing to the ovary include deep myometrial invasion of the primary uterine tumor and bilateral involvement of the ovaries with capsular involvement.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In addition, the presence of endometriosis in the ovary or atypical endometrial hyperplasia in the uterus is also helpful in favoring one organ over another as the primary site. </B></div> <bR> <div> <B><IMG SRC="0eeb0440.png" border=0 width="432" height="324" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">endometrioid carcinoma</B></div> <bR> <div> <B> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="988" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#000099 > <tR> <tD VALIGN=TOP HEIGHT= 246 WIDTH="976"><div> <B><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Borderline (Low Malignant Potential)-</B><B>This is a category of ovarian cancers which have subtle features of malignancy but have an indolent prognosis and only rarely progress to a more advanced stage. </B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Capsule</B><B>-This is the surface epithelial covering of the ovary. The majority of ovarian cancers arise from this epithelium. If a cancer penetrates through this capsule, it is considered a poor prognostic factor.</B></div> <bR> <div> <B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sex-Cord Stroma</B><B>-The ovarian stoma is derived from the primitive embyronic tissue which gives rise to the ovary and testis. This tissue is known as sex cords and have the potential to give rise to </B><B>tumors</B><B> found in both males and females. In addition, this stroma may secrete estrogens and androgens producing feminizing or masculinizing features</B></div> <bR> </tD> </tR> </TABLE></B></div> <div> <B>=====================================================================================================================</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. With respect to serous tumors , </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">70% are benign, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">10% are borderline, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and 20% are invasive malignancies.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Serous histology appears to be derived from ciliated tubal epithelium.</B></div> <bR> <bR> <bR> <div> <B>==================================================================================================================</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Of mucinous tumors, 85% are benign. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mucinous histology appears to be derived from columnar endocervical epithelium.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mucinous </B><B>tumors</B><B> represent a spectrum within ovarian </B><B>tumors</B><B>, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">comprising 15% of all ovarian neoplasms. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They are less common than their serous counterparts.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B><B>There are some interesting associations with these </B><B>tumors</B><B> and Peutz-Jeghers syndrome</B><B>.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In addition, there may be co-existing Brenner </B><B>tumors</B><B> or a dermoid cyst, usually with benign mucinous cystadenomas.</B></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="830" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#FFFF00 > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="255"><div> <B>TUMOR TYPE</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>AGE OF PRESENTATION</B></div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> <B>PERCENTAGE OF </B><B>TUMORS</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="255"><div> <B>Benign cystadenomas</B></div> </tD> <tD VALIGN=CENTER WIDTH="256"><div> <B>3-5th decades</B></div> </tD> <tD VALIGN=CENTER WIDTH="299"><div> <B>85%</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="255"><div> <B>Borderline malignancy</B></div> </tD> <tD VALIGN=CENTER WIDTH="256"><div> <B>4-7th decades</B></div> </tD> <tD VALIGN=CENTER WIDTH="299"><div> <B>6-10%</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="255"><div> <B>Cystadenocarcinomas</B></div> </tD> <tD VALIGN=CENTER WIDTH="256"><div> <B>4-7th decades</B></div> </tD> <tD VALIGN=CENTER WIDTH="299"><div> <B>5-10%</B></div> </tD> </tR> </TABLE></div> <bR> <div> These <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >tumors</FONT> have a varied appearance based upon histological differences.</div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1114" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#FFFF66 > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="197"><div> <B>TUMOR TYPE</B></div> </tD> <tD VALIGN=CENTER WIDTH="396"><div> <B>GROSS APPEARANCE</B></div> </tD> <tD VALIGN=CENTER WIDTH="501"><div> <B>HISTOLOGIC APPEARANCE</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 57 ><NOBR><div> <B>Benign cystadenomas</B></div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> <B>Multilocular and may grow to 30 cm or more</B></div> <div> <B>Thin walls with thick to watery mucinous fluid</B></div> <div> <B>Bilateral <5%</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="501"><div> <B>Epithelial lining resembles endocervical epithelium and less commonly intestinal epithelium with goblet cells</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 208 ><NOBR><div> <B>Borderline malignancy</B></div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Papillae with solid areas</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Necrosis and hemorrhage</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mullerian type </B><B>tumors</B><B> are usually unilocular</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bilateral 5-10%</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="501"><div> <B>Two histologic types:</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mullerian (Endocervical)-Papillae resembling serous borderline </B><B>tumors</B><B> with endocervical lining</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">May have extensive cellular stratification</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Extensive acute inflammation</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intestinal-85-90% of </B><B>tumors</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Papillae uncommon and if present tend to be filiform and branching</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nuclear stratification usually less than 4 layers</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 96 ><NOBR><div> <B>Cystadenocarcinomas</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="396"><div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Papillae with solid areas</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Necrosis and hemorrhage</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bilateral 5-10% but mullerian type </B><B>tumors</B><B> are more often bilateral than intestinal type (40% vs 6%)</B></div> </tD> <tD VALIGN=CENTER WIDTH="501"><div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">May vary from solid to cystic areas and mullerian or intestinal differentiation usually cannot be discerned</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Invasion into the underlying stroma</B></div> </tD> </tR> </TABLE></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Like serous </B><B>tumors</B><B> of the ovary, the critical question which must be answered by the pathologist is whether stromal invasion is present, making the tumor a carcinoma. Most investigators suggest that invasion should be diagnosed only in the presence of the following:</B></div> <div> <I><B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nuclei of the lining cells are stratified to four layers or more</B></I></div> <div> <I><B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cribriform pattern or presence of stroma-free papillae</B></I></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These criteria are applicable only for intestinal type borderline </B><B>tumors</B><B>. Mullerian type </B><B>tumors</B><B>, on the other hand, may show cellular stratification up to 20 layers.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Associated with all mucinous </B><B>tumors</B><B> are occasional stromal nodules usually composed of a high grade carcinoma. Occasional, these mural nodules may resemble a sarcoma. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These nodules are sharply demarcated.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In spite of the ominous histologic appearance, the prognosis for these patients is unchanged from the primary tumor prognosis.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The pathologist must differentiate these </B><B>tumors</B><B> from </B><B>endometrioid</B><B> carcinomas. Since squamous differentiation is very rare in mucinous </B><B>tumors</B><B>, this feature would favor an </B><B>endometrioid</B><B> carcinoma. In addition, some metastatic adenocarcinomas to the ovary may be difficult to exclude. Features favoring a metastasis inlcude metastatic implants on the surface of the ovary and prominent vascular invasion. There may be a mixture of mucinous epithelial types and more goblet cells in primary mucinous </B><B>tumors</B><B>.</B></div> <div> <B>=================================================================================================================</B></div> <div> <B>Sex Cord - Stromal </B><B>Tumors</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ovarian Fibromas and Thecomas </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sertoli- Leydig cell </B><B>tumors</B></div> <bR> <div> <B>Ovarian Fibromas and Thecomas</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Relatively rare benign neoplams</B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibromas </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Occur during middle age </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">frequently asymptomatic </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Meigs Syndrome </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ascites, pleural effusions, and fibromatous tumor of the ovary</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Basal Cell Nevus Syndrome </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Multiple basal cell carcinomas, keratocysts of the mandible, ovarian fibromas</B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thecomas </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rarely malignant </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Occasionally associated ascites or Meigs’ syndrome </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Considered most common hormonally functioning ovarian tumor</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">U/S </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypoechoic mass with posterior shadowing </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">DDx- Pedunculated fibroid</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solid echo texture with marked attenuation of the ultrasound beam </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cystic degeneration can occur</B></div> <div> <B>=================================================================================================================</B></div> <div> <B>Sertoli - Leydig cell </B><B>tumors</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Less than .5% of all ovarian </B><B>tumors</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Occur in all age groups </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some assoc. with hyperestrinism </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Virilizing referred to as Arrhenoblastoma</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Well differentiated is Sertoli cell tumor with minimal Leydig cells </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intraperitoneal spread is more common than distant mets </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Five year survival 70-90%</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Imaging </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Variable appearance depending on internal degeneration,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> degree of vascularity,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and cystic change within tumor</B></div> <bR> <div> <B><IMG SRC="0edf0640.jpg" border=0 width="496" height="356" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is a very rare ovarian tumor which has classically been grouped in the sex cord-stromal cell </B><B>tumors</B><B>.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These </B><B>tumors</B><B> are known for producing various hormones and about 1/3 of cases may present with virilization.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In other patients, oligomenorrhea followed by amenorrhea may occur. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Progressive masculinization and hirsuitism may also occur. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">However, 50% of these patients may have no endocrine symptomatology and instead have abdominal pain or swelling. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Removal of the tumor results in a nomral menses in about 4 weeks.</B></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="479" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 45 WIDTH="162"><div> <B>INCIDENCE</B></div> </tD> <tD VALIGN=CENTER WIDTH="302"><div> >0.5% of all ovarian tumors</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 75 WIDTH="162"><div> <B>AGE RANGE-MEDIAN</B></div> </tD> <tD VALIGN=CENTER WIDTH="302"><div> Mean 25 years</div> <div> 75%<30 years</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1000" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#990000 > <tR> <tD VALIGN=CENTER HEIGHT= 20 ><NOBR><div> <B>LABORATORY/RADIOLOGIC/OTHER TESTS</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="617"><div> <B>CHARACTERIZATION</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 ><NOBR><div> <B>Serum hormones may be elevated</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="617"><div> <B>Elevated levels of testosterone, androstenedione</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 ><NOBR><div> <B>Urinary hormones may be elevated</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="617"><div> <B>Urine 17-ketosteroids</B></div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1003" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#0000FF > <tR> <tD VALIGN=CENTER HEIGHT= 58 WIDTH="216"><div> <B>GROSS APPEARANCE/CLINICAL VARIANTS</B></div> </tD> <tD VALIGN=CENTER WIDTH="772"><div> <B>CHARACTERIZATION</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 57 WIDTH="216"><div> <B>General</B></div> </tD> <tD VALIGN=CENTER WIDTH="772"><div> <B>Usually unilateral</B></div> <div> <B>1.5% bilateral</B></div> <div> <B>Average size 13.5 cm ranging from 5-15 cm</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 58 WIDTH="216"><div> <B>Appearance</B></div> </tD> <tD VALIGN=CENTER WIDTH="772"><div> <B>Variable appearance but usually do not have as much blood filled cysts and are almost never unilocular</B></div> <div> <B>Poorly differentiated </B><B>tumors</B><B> have more necrosis or hemorrhage</B></div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1008" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#FF0000 > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="260"><div> <B>HISTOLOGICAL TYPES</B></div> </tD> <tD VALIGN=CENTER WIDTH="733"><div> <B>CHARACTERIZATION</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 117 WIDTH="260"><div> <B>Well differentiated</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>Usually a tubular pattern with a nodular architecture with fibrous bands separating lobules</B></div> <div> <B>Tubules lined by round to oval nuclei resembling prepubertal or atrophic testicular tubules</B></div> <div> <B>Minimal nuclear atypia and rare mitotic figures</B></div> <div> <B>Stroma with variable amounts of Leydig cells</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 121 WIDTH="260"><div> <B>Intermediate or Poorly Differentiated</B></div> </tD> <tD VALIGN=CENTER WIDTH="733"><div> <B>Immature Sertoli cells have small, round, oval, or angular nuclei arranged in ill-defined masses, creating a lobulated appearance</B></div> <div> <B>Solid and hollow tubules resembling sex cords of embryonic testis</B></div> <div> <B>Broad columns of Sertoli cells</B></div> <div> <B>Stroma may be composed of immature mesenchymal cells resembling a sarcoma</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 97 WIDTH="260"><div> <B>Retiform</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>15% of </B><B>tumors</B></div> <div> <B>Tubular structures resembling rete testis</B></div> <div> <B>May have columns or ribbons of immature Sertoli cells</B></div> <div> <B>Encountered in </B><B>tumors</B><B> with intermediate, poorly differentiated, or heterologous </B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="260"><div> <B>Heterologous</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>Occur in 20% of </B><B>tumors</B><B>, usually intermediate to poorly differentiated </B><B>tumors</B><B> </B></div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1010" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#FFFF00 > <tR> <tD VALIGN=CENTER HEIGHT= 39 WIDTH="224"><div> <B>PROGNOSIS AND TREATMENT</B></div> </tD> <tD VALIGN=CENTER WIDTH="771"><div> <B>CHARACTERIZATION</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 113 WIDTH="224"><div> <B>Prognostic Factors</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>Stage of tumor is important</B></div> <div> <B>Stage Iai in 80% of </B><B>tumors</B></div> <div> <B>Tumor rupture or involves the external surface of the ovary in 12%</B></div> <div> <B>Ascites in 4%</B></div> <div> <B>Spread beyond the ovary within the pelvis or upper abdomen in 2.5%</B></div> <div> <B>Poorly differentiated were more often ruptured or presented at a higher stage </B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 113 WIDTH="224"><div> <B>Survival</B></div> </tD> <tD VALIGN=CENTER WIDTH="771"><div> <B>In Stage I </B><B>tumors</B><B>:</B></div> <div> <B>Well differentiated </B><B>tumors</B><B>-0% malignant</B></div> <div> <B>Intermediate-11% malignant</B></div> <div> <B>Poorly differentiated-59% malignant</B></div> <div> <B>Heterologous elements-19% malignant</B></div> <div> <B>Retiform </B><B>tumors</B><B> with intermediate differentiation-25% malignant</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 39 WIDTH="224"><div> <B>Recurrence</B></div> </tD> <tD VALIGN=CENTER WIDTH="771"><div> <B>66% of malignant </B><B>tumors</B><B> recurred within 1 years</B></div> <div> <B>6.6% recurred after 5 years</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="224"><div> <B>Metastasis</B></div> </tD> <tD VALIGN=CENTER WIDTH="771"><div> <B>Lung, scalp, supraclavicular lymph nodes, liver</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="224"><div> <B>Treatment</B></div> </tD> <tD VALIGN=CENTER WIDTH="771"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="771" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 58 WIDTH="224"><div> <B>Young women with stage I </B><B>tumors</B></div> </tD> <tD VALIGN=CENTER WIDTH="771"><div> <B>Unilateral salpingoophorectomy</B></div> <div> <B>If poorly differentiated elements or heterologous elements are present, adjuvant therapy may be indicated with radiation or combination chemotherapy</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 39 WIDTH="224"><div> <B>Stage II or higher</B></div> </tD> <tD VALIGN=CENTER WIDTH="771"><div> <B>TAH-BSO </B></div> <div> <B>May consider adjuvant therapy</B></div> </tD> </tR> </TABLE></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Brenner tumors, with histology that appears to be derived from transitional cell epithelium, are seldom malignant.</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Very uncommon </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1-2% of all ovarian neoplasms </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually discovered incidentally at surgery </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vast majority are benign</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solid and firm </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dense fibrous stroma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Difficult to distinguish from other solid neoplasms such as fibromas, thecomas, and pedunculated leiomyomas of uterus</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Germ Cell Neoplasms </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">WHO Histologic Classification </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1) Germ Cell </B><B>Tumors</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2) Germ Cells and Sex Cord - Stromal Derivatives</B></div> <div> <B>Germ Cell </B><B>Tumors</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dysgerminoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endodermal Sinus Tumor </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Embryonal Cell Carcinoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Choriocarcinoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Teratomas (mature or immature) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Struma Ovarii </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Carcinoid</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2-3% of ovarian malignancies </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Occur predominantly in young patients </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Frequently produce hCG or AFP</B></div> <bR> <div> <B>Germ Cells and Sex Cord - Stromal Derivatives</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gonadal blastomas </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mixed germ cell and sex cord-stromal </B><B>tumors</B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dysgerminoma</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ovarian Seminoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Composed of germ cells </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Uncommon </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1 to 2% of primary ovarian neoplasms </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3 to 5% of ovarian malignancies</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Majority in adolescence but can occur at any age </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually unilateral but bilateral in 10-15%</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solid Round, oval, or lobulated with slightly glistening fibrous capsule</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Can be up to 50cm in size Histo similar to seminoma</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Can be associated with other neoplastic germ cell </B><B>tumors</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rapidly growing </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mets through lymphatics in the vicinity of the tumor, hematogenous spread occurs later in disease </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5 yr survival 75-90%</B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Teratomas  are rarely malignant.</B></div> <div> <B>WHO classification </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mature (90%) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Immature </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Struma ovarii and carcinoid </B><B>tumors</B></div> <bR> <div> T<B>eratoma - Mature</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5-25% of all ovarian neoplasms </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most commonly in child bearing years </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solid and cystic masses with nodular or smooth contours </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Often discovered as incidental finding </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1-2% show malignant change</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">8-15% Bilateral 60% measure 5-10cm </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Can be up to 40cm</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Protuberance of soft tissue arising from the mass </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rokitansky’s protuberance</B></div> <div> <B>Many Descriptions </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Echogenic, acoustically shadowing, inner mural component (Teeth, Hair, or Sebum) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Unilocular or multilocular cyst with either internal echoes or mural echogenic mass </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fat/Fluid or Hair/Fluid level </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Poorly echogenic mass with either a very echogenic or echopoor center</B></div> <div> <B>Teratoma - Mature CT</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fat/Fluid level </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mural calcifications </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Calcification, bone, or enamel in a mass with associated fat is virtually diagnostic</B></div> <div> <B><IMG SRC="0eba0320.jpg" border=0 width="416" height="306" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> T<B>eratoma - Immature</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2nd most common malignant ovarian germ cell tumor </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">75% during first two decades </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rarely bilateral </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Grow rapidly, cause pain early </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2/3 confined to ovary </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pure teratomas do not produce hCG or AFP</B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Embryonal Carcinoma</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Least differentiated germ cell tumor </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually found as part of a mixed germ cell tumor </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aggressive malignancy that tends to metastasize early</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Choriocarcinoma</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pure ovarian choriocarcinoma of germ cell origin is a very uncommon neoplasm </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">May originate as </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">primary gestational carcinoma associated with ovarian pregnancy </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">metastatic focus from primary gestational carcinoma elsewhere in genital tract </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">germ cell tumor differentiating in the direction of trophoblastic structures</B></div> <bR> <bR> <div> <B><IMG SRC="0e994430.jpg" border=0 width="404" height="323" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Clear Cell Carcinoma</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5-11% of all 1O ovarian carcinomas </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5th to 8th decades </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">40% Bilateral </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2-30 cm in size </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most are cystic with areas of hemorrhage </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Similar survival rates as </B><B>endometrioid</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endodermal Sinus Tumor </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Uncommon </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2nd most common after dysgerminoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Also known as </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Yolk sac tumor </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mesonephroma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mesoblastoma of Vitellinum </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Teilum tumor</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Peak incidence 19yrs </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Range of 16mos to 46yrs </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pure or mixed </B><B>tumors</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually solid, highly malignant </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">90% survival with combination chemo </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">AFP elevated in these </B><B>tumors</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Masses tend to be large Mets by lymphatic system to </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Liver </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Peritoneum </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lymph nodes </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bowel </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lungs</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">15% associated with mature cystic teratomas</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">U/S </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Large, predominantly cystic mass measuring 20-30cm in greatest diameter </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">large, solid, soft tissue components with low-level echoes intermixed with numerous septations</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><IMG SRC="0e7a3470.jpg" border=0 width="419" height="327" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B>Struma Ovarii</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2-3% of ovarian teratomas </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thyroid tissue in a teratoma that has </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">overgrown all other tissues or </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">only the thyroid tissue has developed</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually <10 cm in diameter</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tumor similar to mature thyroid tissue </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually benign but few cases of malignant change have been reported </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Malignancy usually a follicular pattern but papillary has also been observed</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Imaging </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cannot be separated from that seen in adult cystic teratoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If enough iodine has been accumulated, nonenhanced CT can show areas of dense homogeneous soft tissues</B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Primary Ovarian Sarcomas</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Comprise < 3% of ovarian neoplasms </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Up to 40cm in diameter </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Includes: </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rhabdomyosarcoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">stromal cell sarcoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fibrosarcoma </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">leiomyosarcoma</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Many may arise in preexisting teratoma</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Imaging </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Appearance depends on degree of internal hemorrhage, necrosis, and cystic change in these </B><B>tumors</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solid mass of varying echotexture on U/S</B></div> <bR> <div> <B>Metastases</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ovaries and vagina most common site of mets to female genital tract </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">81% of mets involve these two locations </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Four pathways of spread </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Direct invasion </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lymphatic metastasis - Most Common </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hematogenous spread </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">peritoneal implantation</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">GI tract and breast adenocarcinoma are the two most common extragenital sites </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endometrial and cervical carcinoma are the two most common intragenital sites </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bilateral mets in 50-80% of cases</B></div> <bR> <bR> <div> <B>Metastases - Krukenberg Tumor </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Originally described by Krukenberger in 1896 - </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">six cases of unusual bilateral ovarian </B><B>tumors</B><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">later proved to arise from stomach</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The presence of any mets to ovaries has become to become synonymous with “Krukenberg tumor” </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">More common to find colonic met than a gastric met </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually large and associated with poor prognosis</B></div> <bR> <div> <B><IMG SRC="0ef26d80.jpg" border=0 width="550" height="472" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>Metastases - Primary Breast</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">20 -30% incidence of ovarian involvement by primary breast cancer </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rarely result in clinically apparent ovarian disease</B></div> <bR> <div> <B>Metastases - U/S and CT</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">U/S variable appearance </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Depends on solid and cystic components</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CT </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">35-40% predominantly cystic </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">30-40% were mixed solid and cystic </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">20% predominantly solid</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Difficult to distinguish between primary ovarian and mets</B></div> <div> <B><IMG SRC="0f4c71d0.jpg" border=0 width="711" height="797" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B>===================================================================================================================================</B></div> <div> A 21-year-old woman, gravida 2, now para 2, was admitted at 41 weeks' gestation to the labor and delivery suite at 5-cm dilatation with spontaneous onset of contractions. After 3 hours of labor, she underwent an elective outlet forceps delivery of a 3778-g (8 lb 5 oz) female neonate. After the third stage of labor, she experienced a postpartum hemorrhage of 1000 ml due to uterine atony. Which of the following anaesthetic modalities is the most likely cause of the hemorrhage</div> <div> <B>Magnesium sulfate</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hemostasis after delivery of the placenta is dependent on uterine myometrial contractions to close the large venous sinuses through which the uteroplacental circulation passed. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Any agent that causes relaxation of the smooth muscle of the uterus can lead to postpartum hemorrhage.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Magnesium sulfate is a commonly used tocolytic agent.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Bupivacaine epidural analgesia , paracervical block, morphine sulfate , and meperidine hydrochloride are all obstetrical anesthetics that have no impact on myometrial contractility; thus, they do not contribute to uterine atony.</B></div> <bR> <bR> <div> <B>the three stage of labor:</B></div> <div> <B>first stage :</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dilation of the cervix : from onset of labour to full dilation of the cervix</B></div> <div> <B>second stage:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delivery of the baby : from full dilatation to delivery of the baby</B></div> <div> <B>third stage:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delivery of the placenta: from delivery to the baby to the delivery of the placenta</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the onset of the labour is defined as : regular painful uterine contraction accompnied by effacement and progressive dilatation of the cervix.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">this is often accompanied by a show : discharge of the blood stained mucus plug, or operculum, from the cervical canal as it shorten and begin to dilate.</B></div> <div> <I><B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rupture of the membrabe is not in its self diagnosis of labour</U></B></I></div> <div> <B>==============================================================================================================================</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The most significant causes of morbidity and mortality in the menopausal years are osteoporosis and heart disease</B>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Postmenopausal estrogen deficiency exacerbates these conditions. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Estrogen replacement after menopause decreases the risks of these conditions. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> high body mass index does pose a risk for cardiovascular problems.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> positive family history for heart disease is her greatest risk factor, therefore arguing most strongly for  being on hormone replacement therapy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">  past history of hot flashes  is not an active problem.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This patient's positive family history for hypertension  and diabetes are potential risk factors for heart disease, but her normal blood pressure and glucose values negate her family history risk.</div> <div> ====================================================================================================================</div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertensive disorders of pregnancy are among the main causes of maternal mortality in the United States. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">  severe preeclampsia. Appropriate management is stabilization, prevention of seizures using magnesium sulfate, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and then prompt delivery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ritodrine , terbutaline, and indomethacin  are tocolytics and would be contraindicated</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Progesterone  administration has no demonstrable indication in severe preeclampsia.</div> <bR> <div> Hypertensive disease in pregnancy is a major cause of maternal and fetal morbidity and mortality. Pregnancy-related hypertension is divided into 4 categories: </div> <div> The first category consists of normotensive, pregnant patients who develop sustained hypertension, proteinuria, and edema after the twentieth week of gestation and are diagnosed with preeclampsia, or pregnancy-induced hypertension. Preeclampsia is responsible for 50-70% of hypertension seen in pregnancy. Mild preeclampsia is characterized by rise in systolic blood pressure of 30 mm Hg, a diastolic blood pressure rise of 15 mm Hg, or an absolute reading of 140/90 mm Hg in a pregnant patient with minimal proteinuria and pathologic edema. Severe preeclampsia is indicated by a systolic blood pressure greater than 160 mm Hg or a diastolic blood pressure greater than 110 mm Hg complicated by significant proteinuria (>5.0 g/d) and evidence of end-organ damage. </div> <div> In the second category, chronic hypertension has onset prior to pregnancy. Blood pressure greater than 140/90 mm Hg is noted prior to the twentieth week of gestation, lacks significant proteinuria or end-organ damage, and continues well after delivery. </div> <div> Pregnant patients with hypertension documented prior to pregnancy may develop preeclampsia. The third category consists of patients with chronic hypertension with superimposed preeclampsia and is responsible for 15-30% of pregnancy-related hypertensive disease. </div> <div> In the fourth category, transient hypertension consists of a blood pressure greater than 140/90 mm Hg without proteinuria or end-organ damage. These initially normotensive women usually become hypertensive late in pregnancy, during labor, or within 24 hours postpartum and return to normal blood pressure readings within 10 days postpartum. </div> <div> <B>Pathophysiology: </B></div> <div> The etiology for preeclampsia remains unknown; however, placental dysfunction may initiate the systemic vasospasm, ischemia and thrombosis that eventually damages maternal organs and causes placental infarction and fetal death. </div> <div> Preeclampsia typically develops after the twentieth week of gestation and encompasses a wide spectrum of clinical signs and symptoms. Mild preeclampsia is indicated by mild hypertension (HTN) with no evidence of end-organ pathology aside from minimal proteinuria (<2.0 g/d). Severe preeclampsia is at the other end of the spectrum with significant hypertension, more pronounced proteinuria (>5.0 g/d), and evidence of end-organ damage from systemic vasoconstriction. The following signs and symptoms can indicate severe preeclampsia: (1) headache, (2) visual disturbances, (3) confusion, (4) abdominal pain, (5) impaired liver function with hyperbilirubinemia, (6) proteinuria, (7) oliguria, (8) pulmonary edema, (9) microangiopathic hemolytic anemia, (10) thrombocytopenia, and (11) fetal growth retardation. </div> <div> Risk factors for preeclampsia include extremes of maternal age, primigravidus state, multiple gestations, molar pregnancy, preexisting HTN, diabetes mellitus (DM), renal disease, preexisting connective tissue disease, vascular disease, prior history of preeclampsia or eclampsia, and family history of preeclampsia or eclampsia. </div> <div> <B>Frequency: </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the US: </B>Preeclampsia complicates approximately 5% of all pregnancies. </div> <div> <B>Mortality/Morbidity: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preeclampsia is one of the most common causes of perinatal morbidity and mortality, resulting in an estimated 35-300 deaths per 1000 births depending upon neonatal support capabilities of the hospital delivering care. This mortality rate is almost double that in normotensive pregnancies.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If unrecognized, preeclampsia can progress to HELLP syndrome and eclampsia. The HELLP syndrome is noted in 5-10% of patients with preeclamptic symptoms and consists of microangiopathic hemolytic anemia, elevated liver enzymes from hepatocellular damage, and low platelets (HELLP). In addition to the signs and symptoms of preeclampsia, most patients present with right upper quadrant (RUQ) abdominal pain, nausea, and vomiting. Unless the ED physician maintains a high index of suspicion, these patients may be misdiagnosed with gastritis, cholecystitis, or hepatitis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The most serious complication of pregnancy-induced hypertension is eclampsia, which is severe preeclampsia complicated by seizures or coma. Eclampsia occurs in approximately 0.2% of pregnancies and terminates 1 in 1000 pregnancies. Seizures and mental status changes in eclampsia are thought to be secondary to hypertensive encephalopathy. Fetal mortality is 13-30% and maternal mortality is 8-36%, with intracranial hemorrhage as the major cause of maternal death.</div> <div> <B>Age: </B></div> <div> Preeclampsia usually occurs at both extremes of reproductive age; however, the risk of preeclampsia is greatest in females younger than 20 years. </div> <div> <B>History: </B></div> <div> Mild preeclampsia presents without clinical evidence of end-organ pathology, except for minimal proteinuria. Severe preeclampsia is indicated by end-organ damage due to systemic vasoconstriction. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Headache</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Right upper quadrant (RUQ) abdominal pain</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Decreased urine output</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Shortness of breath or dyspnea on exertion</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hand and facial edema</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Visual disturbances</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Confusion and apprehension</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nausea and vomiting</div> <div> <B>Physical: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sustained systolic blood pressure (SBP) increases by 30 mm Hg, and diastolic blood pressure (DBP) increases by 15 mm Hg, or absolute BP >140/90 mm Hg.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe preeclampsia - Sustained SBP >160 mm Hg or DBP >110 mm Hg, in addition to end-organ damage</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tachycardia</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tachypnea</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rales</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pulmonary edema</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mental status changes</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertensive encephalopathy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hyperreflexia, clonus</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Localizing neurological deficits</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intracranial hemorrhage</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cerebrovascular accident</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hepatocellular injury</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Generalized edema</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Small fundal height for estimated gestational age</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intrauterine growth retardation (IUGR)</div> <div> <B>Causes: </B></div> <div> The etiology of preeclampsia is not fully understood; however, dysfunction of the uteroplacental bed is thought to cause generalized vasoconstriction, platelet aggregation, and the hypercoagulable state found in preeclampsia</div> <div> <B>Lab Studies: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complete blood count (CBC)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anemia due to the microangiopathic hemolytic anemia and dilution of pregnancy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thrombocytopenia (platelets <100,000), due to HELLP syndrome</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Serum creatinine is elevated due to decreased intravascular volume and decreased glomerular filtration rate (GFR).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Liver function tests (LFTs)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">SGOT > 72IU/L, total bilirubin >1.2 mg/dL, LDH >600 IU/L</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Elevated due to HELLP syndrome</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Coagulation profile</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Normal prothrombin time and partial thromboplastin time (PT/PTT), fibrin split products, and fibrinogen levels</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rule out associated disseminated intravascular coagulopathy (DIC)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urinalysis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Proteinuria</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Positive human chorionic gonadotropin (HCG)</div> <div> <B>Imaging Studies: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CT scan of head</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Obtain in patients with severe preeclampsia and associated neurological deficits.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Utilize to assess for intracranial hemorrhage or cerebrovascular accident.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Transabdominal ultrasound</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Utilize to estimate gestational age.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rule out abruptio placentae, which could complicate severe preeclampsia.</div> <div> <B>Procedures: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">24-hour urine for protein</div> <div> <B>Prehospital Care: </B>EMS personnel should secure an IV line, place the patient on a cardiac monitor and oxygen and transport the patient in the left lateral decubitus position. </div> <div> <B>Emergency Department Care: </B>The goal of management is to limit maternal and fetal morbidity pending delivery of the fetus, the only definitive treatment for preeclampsia. The severity of symptoms and the gestational age of the fetus ultimately determine the course of treatment rendered in the ED. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The mildest form of hypertension in a pregnant patient without proteinuria, edema or evidence of end-organ damage may be managed on an outpatient basis, as this does not meet the diagnostic criteria for true preeclampsia. Prior to discharge, one must discuss the case in detail with the patient's obstetrician and ensure strict reassessment within 48 hours. Each patient must be counseled regarding reasons for immediate return to the hospital.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension and proteinuria constitute preeclampsia. These patients should be admitted to the hospital for an immediate obstetrical evaluation. Keep in mind that hypertension and proteinuria could be due to chronic primary hypertension; however, this is a diagnosis of exclusion and may be considered once preeclampsia has been ruled out.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe preeclampsia is managed in an intensive care setting as if the patient was truly eclamptic.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Magnesium sulfate is given for seizure prophylaxis and hydralazine or certain other antihypertensive drugs are given for blood pressure control.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Care is taken not to drop the blood pressure too drastically, causing inadequate uteroplacental perfusion and fetal distress.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Maintaining a diastolic blood pressure of 90 mm Hg is the goal of antihypertensive therapy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If the gestational age is greater than 30 weeks, delivery is indicated.</div> <div> <B>Consultations: </B>All forms of preeclampsia warrant immediate obstetrical consultation</div> <div> Drug treatment consists of seizure prophylaxis and antihypertensives.</div> <div> Drug Category: <I>Electrolytes</I> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >- Magnesium sulfate has anticonvulsant properties and can be used for seizure prophylaxis. </FONT></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1307" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="183"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> Magnesium sulfate- Used to treat and prevent seizures. For clinically significant hypermagnesemia, calcium gluconate (10% solution), 10-20 mL IV, can be given. </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Adult Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> 2-6 g (20% solution) IV over 5-10 min initial; 1-3 g/h IV maintenance; alternatively, 5 g IM each buttock (10 g total) initial; 5 g IM q4h maintenance </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Pediatric Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1109"><div> 25-50 mg/kg/dose q4-6h for 3-4 doses; not to exceed 2 g; repeat if hypomagnesemia persists </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1109"><div> Documented hypersensitivity; heart block; Addison's disease; myocardial damage; severe hepatitis </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 57 WIDTH="183"><div> <B>Interactions </B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1109"><div> Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may increase neuromuscular blockade seen with aminoglycosides and potentiate neuromuscular blockade produced by tubocurarine, vecuronium, and succinylcholine; may increase CNS effects and toxicity of CNS depressants, betamethasone, and cardiotoxicity of ritodrine </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1109"><div> A - Safe in pregnancy </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 57 WIDTH="183"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1109"><div> Magnesium may alter cardiac conduction leading to heart block in digitalized patients; respiratory rate, deep tendon reflex, and renal function should be monitored when electrolyte is administered parenterally; caution when administering magnesium dose since may produce significant hypertension or asystole; in overdose, calcium gluconate, 10-20 mL IV of 10% solution, can be given as antidote for clinically significant hypermagnesemia</div> </tD> </tR> </TABLE></div> <div> <FONT SIZE="4" COLOR="#000000" FACE="Arial" >Drug Category: <I>Antihypertensives</I> </FONT>- Hydralazine is the DOC for blood pressure control in preeclamptic patients. However, parenteral hydralazine is only provided to pharmacists upon a special emergency request. Therefore, the physician must be comfortable utilizing other antihypertensive agents. Labetalol has alpha- and beta-adrenergic blocking effects and can be utilized to provide rapid control of severe hypertension. Other antihypertensive agents have significant side effects and should not be used as primary agents. Diazoxide may cause hyperglycemia and inhibit labor, and nitroprusside may cause fetal cyanide toxicity. Diuretics should be avoided due to the relative intravascular volume depletion already present in patients with preeclampsia. </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1309" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="186"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1108"><div> Hydralazine (Apresoline)- Decreases systemic resistance through direct vasodilation of arterioles </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="186"><div> <B>Adult Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1108"><div> Initial: 5 mg IV</div> <div> Maintenance: 5-10 mg IV q20-30m </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Pediatric Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1108"><div> 0.1-0.2 mg/kg/dose IV q4-6h prn; not to exceed 20 mg or 1.7-3.5 mg/kg/d divided in 4-6 doses </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1108"><div> Documented hypersensitivity; mitral valve rheumatic heart disease </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Interactions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> MAOIs and beta blockers may increase hydralazine toxicity; indomethacin may decrease pharmacologic effects of hydralazine </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1108"><div> B - Usually safe but benefits must outweigh the risks. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1108"><div> Hydralazine has been implicated in MI; caution in patients with suspected coronary artery disease</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1302" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="183"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1104"><div> Labetalol (Normodyne)- Used as an alternative to hydralazine in eclampsia. It blocks beta 1-, alpha-, and beta 2-aderenergic receptor sites, decreasing blood pressure. It is used as an alternative to hydralazine. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Adult Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1104"><div> 20-30 mg IV initial; double dose q10-20 min; not to exceed 300 mg </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="183"><div> <B>Pediatric Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1104"><div> Not established</div> <div> Suggested dose: 0.4-1 mg/kg/h; not to exceed 3 mg/kg/h </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1104"><div> Documented hypersensitivity; cardiogenic shock, pulmonary edema, bradycardia, atrioventricular block, uncompensated congestive heart failure, reactive airway disease, and severe bradycardia </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 57 WIDTH="183"><div> <B>Interactions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1104"><div> Labetalol decreases effect of diuretics and increases toxicity of methotrexate, lithium, and salicylates; may diminish reflex tachycardia, resulting from nitroglycerin use, without interfering with hypotensive effects; cimetidine may increase labetalol blood levels; glutethimide may decrease labetalol effects by inducing microsomal enzymes </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1104"><div> C - Safety for use during pregnancy has not been established. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="183"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="1104"><div> Caution in impaired hepatic function; discontinue therapy if there are signs of liver dysfunction; in elderly patients, a lower response rate and higher incidence of toxicity may be observed</div> </tD> </tR> </TABLE></div> <div> <B>Further Inpatient Care: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with preeclampsia require admission to the hospital for immediate obstetrical consultation. Patients with severe preeclampsia need supportive care and treatment in an intensive care setting.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hospitalization with bedrest in the left lateral decubitus position may be required.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Seizure prophylaxis (MgSO<FONT SIZE="1" COLOR="#000000" FACE="Arial" >4</FONT>) and antihypertensive agent (hydralazine) are required for severe preeclampsia.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Delivery is the definitive treatment.</div> <div> <B>Further Outpatient Care: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pregnant patients with hypertension and no proteinuria, edema, or evidence of end-organ pathology may be evaluated on an outpatient basis by an obstetrician within 48 hours of presentation.</div> <div> <B>Transfer: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with severe preeclampsia or eclampsia must be managed in a high-risk obstetrical facility.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Once the patient with preeclampsia or eclampsia has been stabilized, arrange for immediate transfer to the nearest high-risk obstetrical facility capable of delivering neonatal and maternal intensive care.</div> <div> <B>Complications: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Abruptio placentae with disseminated intravascular coagulopathy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Renal insufficiency or failure</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">HELLP syndrome</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Eclampsia</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cerebral hemorrhage</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Death</div> <div> <B>Prognosis: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Generally good with appropriate treatment and delivery of fetus</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aspirin blocks the platelet aggregation and vasospastic component of preeclampsia and has proven effective in preventing preeclampsia. However, its use has been associated with increased risk for abruptio placentae. Aspirin therapy, if used, should be under direct supervision of an obstetrician.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Maintain a high index of suspicion for preeclampsia when evaluating any complaint in a pregnant patient with abnormally elevated blood pressure.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Any pregnant patient, regardless of age, is at risk for preeclampsia.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Immediate obstetrical consultation is required for all preeclamptic patients</div> <div> to resume</div> <bR> <div> <B>Pregnancy Induced Hypertension Preeclampsia </B></div> <div> <B>Eclampsia </B></div> <bR> <bR> <bR> <div> <B>Definition </B></div> <div> <B>Eclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">"sudden flash" </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">"shining forth" </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">EPH gestosis </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Edema </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Proteinuria </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Toxemia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">"toxin present" </B></div> <bR> <bR> <div> <B>Epidemiology </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Incidence </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">All births: 4-6% </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preterm births: 20% </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mortality: 100,000 maternal deaths per year worldwide </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Accounts for 10-30% of all maternal deaths yearly </B></div> <bR> <bR> <div> <B>Pathophysiology </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Decreased Intravascular volume </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hemoconcentrated </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Increased Hemoglobin </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Increased Vascular Resistance </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endothelial Cell dysfunction </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Very active organ system (not just vessel lining) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Surface Area >6300 square meters over 100g of tissue </B></div> <div> <B>Associated findings </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Edema </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Proteinuria </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Coagulation abnormalities </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Multiple system effects by oxygen free radicals </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Perfusion and re-perfusion injury </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lipid peroxidation </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antioxidant mechanisms are protective </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trophoblastic Invasion </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Two phases </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">First: decidua </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Second: 12-18 weeks gestation </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Effects of PIH are reversed with Trophoblast delivery </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Model System </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pregnant ewes </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Used to study prostaglandin synthesis inhibitor </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension is a major mental roadblock </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prevents understanding and treatment of toxemia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension is an effect of PIH, not a cause </B></div> <bR> <bR> <div> <B>Classification </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pregnancy Induced Hypertension (PIH) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension without Proteinuria or pathologic edema </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preeclampsia with Proteinuria or pathologic edema </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mild Preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe Preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Eclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Convulsions </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Proteinuria </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Edema </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">HELLP Syndrome </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hemolysis </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Elevated Liver Function Tests </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Low platelets </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pregnancy Aggravated Chronic Hypertension </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Superimposed preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Superimposed eclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Coincidental Hypertension (Chronic Hypertension) </B></div> <bR> <bR> <div> <B>Risk Factors </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Primigravid or new paternity </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Family History (25%) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Diabetes Mellitus </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Multiple gestation </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Obesity </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Extremes of maternal age </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preexisting Hypertension </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hydatiform mole </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fetal Hydrops </B></div> <bR> <bR> <div> <B>Symptoms (onset after 20 weeks gestation) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hand and face edema </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Headache </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Visual disturbance </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epigastric pain </B></div> <bR> <bR> <div> <B>Signs: General </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Excessive weight gain </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood Pressure </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mild preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood Pressure exceeds 140/90 or </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Elevation of 30/15 over baseline Blood Pressure </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Two supine Blood Pressures, 6 hours apart </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood Pressure exceeds 160/110 </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hyperreflexia and clonus </B></div> <bR> <bR> <div> <B>Signs: Severe Preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine Output decreased </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine output less than 400-500 ml in 24 hours </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pulmonary edema </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cyanosis </B></div> <bR> <bR> <div> <B>Labs </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine Protein and 24 Hour Urine Protein </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mild Preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine chemstrip exceeds 1+ protein </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine Protein exceeds 300 mg in 24 hours </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe Preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine chemstrip exceeds 2+ protein </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine Protein exceeds 3500 mg in 24 hours </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Urine for single Specimen protein to creatinine ratio </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Correlates with 24 Hour Urine Protein </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">PIH unlikely if protein to creatinine ratio < 0.15 </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Needs confirmation by larger study </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reference </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Young (1996) J Fam Pract 42:385-9 </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complete Blood Count with platelets </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Serum Electrolytes </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Renal Function testing </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood Urea Nitrogen (BUN) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Creatinine </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Uric Acid </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Liver Function Tests </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aspartate Aminotransferase </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Alanine Aminotransferase </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Serum Bilirubin </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Coagulation Studies for severe preeclampsia or HELLP </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Protime (PT) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Partial Thromboplastin Time (aPTT) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibrin split products (Fibrin Degradation Products) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fibrinogen </B></div> <bR> <bR> <div> <B>Diagnostic studies: fetus </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fetal Nonstress Test </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Obstetric Ultrasound </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Biophysical Profile </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Amniocentesis for Fetal Lung Maturity when indicated </B></div> <bR> <bR> <div> <B>Monitoring </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mild Preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Repeat labs every day to weekly </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe Preeclampsia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Repeat labs every 4-6 hours </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Follow Serum Magnesium level on Magnesium Sulfate </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thrombocytopenia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Check platelets every 4 hours in labor </B></div> <bR> <bR> <div> <B>Complications for fetus </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neonatal Asphyxia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neonatal Hypoglycemia </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intrauterine Growth Retardation </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B></div> <bR> <div> <B> <IMG SRC="0f2f94c0.png" border=0 width="761" height="588" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B><IMG SRC="0f310980.png" border=0 width="528" height="408" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>===================================================================================================================================</B></div> <bR> <bR> <div> following correctly identifies the sequence of cardinal movements of labor that a fetus undergoes prior to delivery</div> <div> <B>Descent, flexion, internal rotation, extension, external rotation</B></div> <bR> <bR> <bR> </td> </tr></table></body>