DEPARTMENT OF OBSTETRIC &
GYNAECOLOGY
KULLIYYAH OF MEDICINE
INTERNATIONAL ISLAMIC UNIVERSITY
MALAYSIA
CASE WRITE UP GYNAECOLOGY
YEAR 5 BLOCK 3 (2017/2018)
CERVICAL CARCINOMA
Name : Mohammad Aiman bin Mohd Shah
Matric No : 1314027
Supervisor : Dr Raja Arif Shah
IDENTIFICATION DATA
Name: Mazenah binti Min
Identification Card No: 570408-11-5114
RN: 1047253
Age: 60 years old
Race: Malay
Occupation: Pensioner
Address : Beserah, Kuantan
Marital Status: Married
Para: Para 5
Date and Time of Admission: 14th December 2017
Date and Time of Clerking: 15th December 2017
CHIEF COMPLAINT
Mdm. Mazenah was electivley admitted for further management in view of post-coital
bleeding for the past 5 months duration.
HISTORY OF PRESENTING ILLNESS
She was apparently well until 5 months ago when she started to have per vaginal bleeding
each time after inercourse. She describe the event when she bleeds minimal amount of fresh blood
which soaked about one-third of the pad. The bleeding lasted about 15 minutes to an hour and
she did not have to wear pad afterward. In January 2016- 3 months prior to presentation, the
symptoms worsened as she claimed that the amount increased to soak half of the pad and was
assciated with small 50 cents-sized clots. She claimed to usually have sexual intercourse once
every two weeks and the last sexual activity was in Jnaury 2016, after the bleeding got worse.
She did complain of mild vaginal dryness since having menopuase but claimed that it only
minimally affect the citus. Otherwise, the post-coital
PHYSICAL EXAMINATION
General examination
She was lying comfortably on her bed on supine position. She was alert and conscious.
She is a medium built lady. She was not cachexic. She is not pale or jaundice. There was a branula
on the left dorsum of her hand. Hydration status and oral hygiene was good. There was no
palpable lymph node. There was no bipedal oedema.
Vital signs
Blood pressure: 110/60mmHg (normotensive)
Respiratory rate: 20 breaths per minute (normal)
Pulse rate: 90 beats per minute, good volume, regular rhythm
Temperature: 37oC (afebrile)
Anthropometric measurement
Height: 155 cm
Weight: 64 cm
BMI: 26 Kg/m2 (pre- obese)
Abdominal Examination
On inspection, the abdomen was not distended with a caesarean scar measuring 15cm
which was well healed with no keloid formation. No uterine scar tenderness. On palpation, the
abdomen was soft and non-tender. There was no mass palpable. There was no
hepatosplenomegaly and the kidneys were not ballotable. On percussion, the abdomen was
resonance at all 9 quadrants. On auscultation, bowel sound was present.
Neck Examination
There were no obvious lumps or anterior neck swelling observed. There was no palpable
mass and no cervical, axillary and inguinal lymph node palpable. The thyroid gland was not
enlarged.
Involvement and it serves as baseline for
future reference.
Renal Profile
Urea 3.0 mmol/L
Sodium 141 mmol/L
Potassium 3.5 mmol/L
Chloride 106 mmol/L
Creatinine 67 umol/L
Reason Comment
Pre-operative assessment No derangement
Advanced stage, renal involvement
can cause impaired renal function
This reading also serves as baseline
for future reference
Coagulation Profile
PT 12.5 sec
INR 1.0
APTT 35.2 sec
APTT ratio 0.9
Reason Comment
Pre-operative assessment None of the above was prolonged
To rule out any coagulation to suggest underlying coagulation
disorders disorder
Ultrasonography
Reason Comment
To screen for any abdominal Not done
masses or changes in
abdominopelvic region
Electrocardiogram
Reason Comment
Pre-operative assessment Normal
Chest X-Ray
Reason Comment
Pre-operative assesment to rule out No abnormalities noted
any active lung disease
Look for any evidence of
metastasis to the lungs
CT scan (Thorax, Abdomen, Pelvis)
Reason Comment
To asses the involvement of lymph Not yet done, Planned after one
nodes at the thoracic region, week of discharge.
abdomen and pelvic region and
other possible organs metastasis-
which will aid in staging
Examination Under Anaesthesia (EUA) & Hysteroscopy
There were no abnormalities noted at vulva, lower third and upper third of vagina. There
was endophytic growth from 12 to 6 o’clock which measured less than 3 cm. Endocervix
appeared fluffy and the whole length of endometrium was noted to be atrophic. Right and
left parametrium were free. On bimanual examination, uterus was at 6 weeks of size. Per-
rectally, there was no mass palpable.
Cystoscopy
There were no abnormalities noted at external meatus, bladder trigone, dome of bladder as
well as other walls of bladder.
MANAGEMENT AND PROGRESSION IN WARD
The patient was referred from Klinik Al Farabi in view of post coital bleeding for the past
5 months and atypical endocervical cells which favours neoplasm on Pap Smear. Colposcopy on
the first appointment at gynaecology clinic at HTAA revealed abnormal growth that suggest
invasive cancer. Examination Under Euthanasia(EUA), hysteroscopy and dilatation and curettage
(DD&C), also with cystoscopy was done for further evaluation. Intraoperative findings were as
noted in the investigation section and she was diagnosed with cervical carcinoma stage 1b1
according to International Federation of Obstetricians and Gynaecologist (FIGO) staging in
which clinical lesion are no greater than 4 cm in size. Histopathology examination result was still
pending. Post-procedure, her vital signs were monitored in the ward and she was also put on pad
chart. She was allowed orally as tolerated. Mefenamic acid 250 mg BD was also given for pain
management. She was noted to be hemodynamically stable with only minimal discomfort over
the suprapubic and perineal area but otherwise ambulating well, passing urine and flatus without
problems. The pad chart was also nil. The patient was thoroughly explained about her current
condition and she understood. She was then allowed discharge the next day and was given
appointment for CT scan in the week to come and attend back at Gynaecology clinic one week
after the CT scan.
DISCUSSION
According to Malaysian National Cancer Registry Report (MCNR) 2007-2011,
cervical cancer is the third most common cancer among women in Malaysia which constitutes
about 7.7% of all female cancers in the country. The incidence rate is shown to increase after the
age of 30years old and peak at the age of 65 to 69 years old. After the emergence of screening
method and widespread use of it, namely Papanicolaou smear, the incidence of cervical cancer
has dramatically reduced, especially in developed countries. This screening method provides an
early recognition of abnormal cytologic changes and with appropriate intervention, this will
prevent the progression of the disease from pre-invasive to invasive (Canavan & Doshi, 2000).
Generally, malignant tumours can arise from the epithelium or from mesenchymal tissue. But the
two major histologic types of cervical cancer are the squamous cell carcinoma and
adenocarcinoma in which the former constitute the majority of cervical cancer.
Identifying the woman at risk of developing cervical cancer is very crucial to make the
screening programme more efficient and effective. One of the most important etiologist that has
been implicated in the development of premalignant and malignant change in the cervix would
be infection with human papilloma virus (HPV) which is a sexually transmitted infection spread
by skin to skin contact during the intercourse, hence the use of condoms does not protect a woman
from getting infected. It can also spread through oral, and anal sex. It is highly contagious with
or without symptoms. The known HPV types that carry the oncogenic properties would be 16,
18, 31, and 33- particularly the first two in the list. The likelihood of the infection increase in
certain types of sexual behaviour- and this include sexual intercourse at young age (< 18 years
say, need further evaluation and based on the American Society of Colposcopy and Cervical
Pathology recommendation, in this pattern of case, colposcopy and endocervical curettage are
needed (Kaferle & Malouin, 2001), which was done in this patient. Based on the colposcopy
result, the abnormal growth favours invasive carcinoma on the basis of its bleeds on contact, its
extension into the endocervix and negative iodine uptake. The latter is attribute to the fact that
precancerous lesions and invasive cancer do not take up iodine as they lack of glycogen.
Assessing the stage of the disease is crucial for prognostication and planning for
treatment. The tumours are locally infiltrative in the pelvic area, but also spread via lymphatics
and in the late stages via blood vessels. The tumour can grow through the cervix to reach the
parametria, bladder, vagina, and rectum. Metastases can occur in pelvic (iliac and obturator
nodes) according to the system introduced by the International Federation of Obstetricians and
Gynaecologist (FIGO) staging system is largely based upon physical examination and a limited
number of endoscopic diagnostic procedures and imaging studies as listed below.
1. Physical examination
a. Pelvic examination-speculum, bimanual and rectovaginal examination for palpation
and inspection of the primary tumour, uterus, vagina, and parametria
b. Examination for distant metastasize- palpation of groin and supraclavicular lymph
nodes, examination of the right upper quadrant.
2. Cervical biopsy
a. Colposcopy
b. Endocervical curettage
c. Conization
3. Endoscopy
a. Hysterectomy
b. Cystoscopy
c. Proctoscopy
4. Imaging
a. Intravenous pyelogram-evaluate urinary tract
b. Computed tomography (CT scan) or MRI
c. Chest X-ray
