Fimbrial cyst

This is a case of 38yrs old female patient  presenting with pain abdomen. 

Ultrasound diagnosis was ovarian cyst. During surgery that was found out to be large fimbrial cyst and removed.

Vulval leukoplakia - definition, causes, pathogenesis, symptoms and signs, diagnosis, prevention, treatment, differential diagnosis

 Definition:

Generally benign keratotic white lesions on the vulva are called as vulval leukoplakia or precancerous disease or white spot disease.

In these more are benign or pre-cancerous lesions. Only 4 to 6% can be cancerous.

Nowadays instead of using the general term leukoplakia, one standard nomenclature has developed based on the histopathological findings of the vulval lesions.

And these lesions are called non-neoplastic epithelial disorders in general. And these are subdivided into:

-Squamous cell hyperplasia.

-Lichen sclerosus.

-And other dermatoses.

Causes of leukoplakia:

Exact etiology is not clear. But the possible factors are:

-Systemic factors like:  

    Diabetes

    Endocrine disorders

    Malnutrition

   Vitamin deficiency

   Pituitary-ovarian dysfunction

-EB virus infection

-Candida albicans infection

-HPV infection seen in around 22% of the patients.

-Can be seen in patients with oral leukoplakia.

-P 53 gene mutation leading to cell proliferation.

-Local factors like:

   Genital partial wetness

   Heat stimulation

   Rubbing

  Age related atrophy

-Previous similar lesions

-The skin graft to vulva can also get the lesions.

Pathogenesis:

It is a mucosal or epidermal epithelial proliferative lesion.

In leukoplakia mucosal epithelium becomes keratinized ranging from granular layer thickness.

Histopathological features:

-Significant hyperkeratosis

-Granular layer thickening

-Mucosal or skin epithelial hyperplasia

-Acanthosis thickening

-Epithelial crest

-Infiltration of dermal lymphocytes and plasma cells

-Appearance of prickle cell layer

-Cells with irregular shape and mitotic figures

Symptoms and signs:

-Patient will usually present with irregular milky white shiny patches or plaques with slightly elevated mucosal surface, well defined borders and state clearly.

These lesions can be seen on genital organs like vaginal mucosa, urethral mucosa, clitoris, labia majora, labia minora etc.

Itching is one more common feature.

Itching can lead scratching, rubbing which can in turn lead to flushing, edema, erosion, ulcers or liquenification.

With progression of time some lesions can become:

-Uplifted, state unclearly

-Surface becomes more keratinized, rough and hard to touch.

-Bleeding from the erosion or ulcers can be seen.

Diagnosis:

Histopathological examination and clinical features collectively help in diagnosis.

Prevention:

-Pertinacious diet containing vitamins, minerals etc. should  include milk, eggs etc.

-Treating provoking factors like diabetes, endocrine diseases etc.

-Treating EB virus, candidial infections etc.

-Maintaining vulval local health like reducing the moisture, friction, heat production etc.

Treatment:

-With appropriate and early intervention around 96 to 97% cases can be prevented from becoming worse.

-Local treatment – to keep the vulva clean and dry.

-Using mild soaps and avoiding soap over scrub etc.

-For itching local corticosteroids can be used.

-For keratosis proliferative lesions topical 0.025% to 0.05% Vitamin-A acid ointment or 2.5% fluorouracil ointment can be used.

(Fluorouracil helps in blocking the conversion of uracil into thymidine. Thereby it inhibits DNA synthesis, which prevents tumor cell proliferation and differentiation. It can be used in precancerous skin lesions and also in malignant skin lesions.)

-Leukoplakia with mild dysplasia can be treated with this combination therapy and long term follow-up.

-In case of leukoplakia lesions with atypical cellular features with possibility of development of carcinoma in situ needs surgery.

Differential diagnosis of leukoplakia :

Keratosis:

-White skin cells due to hypopigmented keratosis with out heteromorphism.

-Appear as ill-defined white spots with no or mild infiltration.

-If the keratosis prolongs for long term it can turn into leukoplakia etc lesions.

Oral lichen planus in combination with genital lichen planus

-Can appear on genital skin or at mucocutaneous junction.

-Usually appears as polygonal flat purple or dark red papules with glossy surface.

-HPE: colloid bodies, basal liquefaction, degeneration, dermal infiltration of lymphocytes etc.

 

Atrophic lichen sclerosis:

-Often occurs on labia.

-It is atrophic vulvar dystrophy.

-Appear as blue and white papules, integrated pale hypo pigmented spots can be seen.

-Can involve anus and vagina to form a dumble – shaped lesions.

-Itching will be minimal usually.

Vulval vitiligo:

-Depigmented spots with clear boundaries can be seen.

-No keratosis or infiltration or itching.

-Same type of lesions can be on other parts of the body.

-HPE: complete lack of dopamine stained melanocytes in the basal layer.

-Easy to differentiate with leukoplakia.

Vulval neurodermatitis:

-Usually distributed on both sides of the outer labia.

-Conscious itching sensation will be present.

-Skin lesions can develop due to continuous scratching.

-HPE: changes of chronic dermatitis, thickening of skin layers can be seen. There will be no spindle shaped cells which will help in differentiating with leukoplakia.

Types of anemia according to RBC indices and causes

 RBC(Red blood cells) indices are part of complete blood picture examination.

Usually measured RBC indices are:
-Number of RBC.
Normal values:
Male: 4.7 to 6.1 million cells /mcL
Female: 4.2 to 5.4 million cells/mcL
Decreased number of RBC indicate anemia.

-MCV (mean corpuscular volume) - the average red blood cell size.
Normal value:  80 to 100 femtoliter

-MCH (mean corpuscular hemoglobin) -the amount of hemoglobin per red blood cell.
Normal value: 27 to 31 picograms/cell

-MCHC (mean corpuscular hemoglobin concentration)- the amount of hemoglobin relative to the size of the cell or hemoglobin concentration per red blood cell.
Normal value: 32 to 36 grams/deciliter

Depending on these indices anemias can be classified as:
-Normocytic and normochromic anemia:
• decreased number of RBC with normal hemoglobin content, MCV and MCHC.
•Causes:
Sudden and significant blood loss Prosthetic heart valve
Tumors
Any chronic disease
Aplastic anemia etc.

-Microcytic and hypochromic anemia:
•decreased number of RBC with low MCV and MCHC.
•causes:
iron deficiency
lead poisoning
thalassemia etc.

-Macrocytic and normochromic anemia:
•decreased number of RBC with high MCV and normal MCHC.
•Causes:
B-12 and/or folate deficiency
Pernicious anemia
Chemotherapy etc.

-Macrocytic and hyperchromic anemia:
•decreased number of RBC with high MCV and MCHC.
•Causes:
Folic acid deficiency
Chronic alcoholism
Using drugs which are having antagonistic activity to folic acid like cotrimoxacol  and triamteren etc.

Weight losing drugs - infertility

Obesity sometimes can lead to infertility by leading to hormonal imbalance.
Obese women are prone for poly cystic ovary disease.
It can also lead to other medical complications like diabetes, hypertension etc, and these can also affect the fertility.
So weight loss can improve the fertility.
But using drugs to loose weight while trying for pregnancy is not advisable.
Because some of these drugs can lead to side effects according to studies.
And they can affect the baby if pregnancy occurs.
Physical exercise and dietary management are the best ways to loose weight.
Any drug should be used only with doctor's prescription and after verifying FDA approval.
Sometimes FDA can recall some drugs after patients reporting side effects.
Example: http://www.fda.gov/forconsumers/consumerupdates/ucm374742.htm
So full information should be gathered before starting any drug. Take care.


(The viewers are invited to ask questions or share opinions related to obstetrics and gynecology through the comment box. Thank you)

Detection of autosomal trisomies in second trimester of pregnancy

Trisomy is a type of polysomy.
In which instead of normal two instances, three instances of particular chromosome can be seen.
 The trisomies that can commonly affect the intrauterine fetus are
trisomy 21 ( Down syndrome), trisomy 18 (Edwards syndrome),
 trisomy 13 Patau syndrome.
The chances of having babies with trisomies increases with maternal age.
The possible risk of these trisomies can be detected during pregnancy by screening tests.
In second trimester:
-Quadruple test:
It is a blood test.
It should be done between 16 to 22 weeks.
In which levels of
AFP (Alfa feto protein)
hCG (Human chorionic gonadotropin)
uE3 (unconjugated estradiol)
Inhibin A are analyzed.

High HCG, inhibin A levels, low AFP and uE3 levels indicate high risk for trisomies especially Down syndrome.
Triple test measures first three and Inhibin A is not included in it.

Amniocentesis:
It is a invasive test and can be used as a diagnostic test.
Can be performed between 16 to 21 weeks.
By this amniotic fluid is collected and possible fetal cells in it are analyzed for chromosomal abnormalities.
It is having little bit higher risk for miscarriage and infections.

TIFFA scan (Targeted imaging for fetal anomalies):
It is a ultrasound examination to detect fetal anomalies.

It should be performed between 18 to 22 weeks.

By combined result of all these investigations one conclusion can be drawn regarding the possibility of trisomies.


Detection of autosomal trisomies in first trimester:
detection-of-autosomal-trisomies-in first trimester

Detection of autosomal trisomies in first trimester of pregnancy

Trisomy is a type of polysomy.
 In which instead of normal two instances, three instances of particular chromosome can be seen.
 The trisomies that can commonly affect the intrauterine fetus are
trisomy 21 ( Down syndrome),
trisomy 18 (Edwards syndrome),
trisomy 13 Patau syndrome.
The chances of having babies with trisomies increases with maternal age.

The possible risk of these trisomies can be detected during pregnancy by screening tests.
In first trimester:
-Double marker test is a blood test which is used to identify the risk of chromosomal abnormalities like trisomies.
It identifies levels of
hCG(human chorionic gonadotropin),
PAPP-A(pregnancy associated placental protein - A) in maternal blood.
In case of possible abnormality, the levels of these substances will be high.
The cutoff values may differ from lab to lab.

-Nuchal Thickness in the ultrasound. Increased nuchal thickness indicates high risk for Down syndrome.

At around 11 to 13 weeks, nuchal thickness less than 3.5 mm can be considered as within normal limits.
 To come to one conclusion combined result of blood test and nuchal thickness should be considered.

Diagnostic tests can give a clear picture.
In first trimester the diagnostic tests that can be performed are:
-CVS (chorionic villi aspiration sampling):
It can be performed between 10 to 13 weeks of gestation.
By this fetal tissue can be obtained and genetically analyzed.
It is true that chorionic villi aspiration sampling is a better test but it is having risks like chances of miscarriage, infection etc.
And it is difficult to perform in situations like low lying placenta.

-Non invasive tests like NIFTY(Non invasive fetal trisomy test).
It is a blood test.
In which maternal blood in drawn and available fetal cells in it are analyzed for chromosomal abnormalities.
As it is a non invasive test, so there is low risk for miscarriage and infection.
It is more useful in situations like low lying placenta.
According to the studies available NIFTY is also having good accuracy in detecting the abnormalities.


Detection of autosomal trisomies in second trimester:
http://srsree.blogspot.com/2014/03/detection-of-autosomal-trisomies-in_13.html

Causes of bleeding from clitoris during menstruation

Some women complain of bleeding from the clitoris during menstruation.
Though it is rare, sometimes this can be seen due to causes like:
-Most common cause is mistaking the normal menstrual flow as clitorial bleed.
Sometimes menstrual blood can get attached to clitoris and can give a picture like bleeding from clitoris.
And the women may attribute it as clitorial bleeding.
-Injuries or abrasions at clitoris. While using tampons sometimes abrasions can occur over clitoris and that can lead to spotting.
Small abrasions may go unnoticed but when spotting occurs from them, that is mistaken as clitorial bleeding.
-Vicarious bleeding.
Sometimes during menstrual flow bleeding can be seen from other parts of the body.
Like that bleeding can occur from clitoris also.
-Presence of ectopic endometrial tissue at the clitoris and that can bleed during periods.
Sometimes endometrial tissue can present outside the uterus also. That can bleeding during menstruation under hormonal influence.