DEPARTEMENT OF OBSTETRICS AND GYNECOLOGY FACULTY OF HEALTH AND MEDICINE

ATMA JAYA CATHOLIC UNIVERSITY OF INDONESIA

RSUD. R. SYAMSUDIN SH, SUKABUMI
JANUARY 7th - MARCH 17th 2019

CASE REPORT

CERVICAL CANCER
AND ANEMIA
Supervised by Presented by
dr. Hesty Duhita Permata., SpOG Clairine Agatha 2017-06010-139
Introduction
Cervical cancer is abnormal cells divide without control in
tissues of the cervix, the organ that connecting the uterus and
vagina, and can invade nearby tissues that forms.
Introduction
• fourth most frequent cancer in
women.
• 90% women in low- and middle-
income countries → death
• Women at age > 35 years old →
high risk.
• 30% to 90% of patients with
cancer had anemia symptoms
C A S E R E P ORT
Patient’s Identity
• Name : Mrs. A
• Date of birth / Age : April 2nd 1980/ 38 years-old
• Nationality : Indonesian
• Address : Jl. Kp. Lingkungansari RT 04 RW 21,
Sukabumi
• Marital status : Married
• Occupation : Housewife
• Religion : Moslem
• Date of admission : February 17th, 2017
• Date of examination : February 17th, 2017
History Taking
P3A1, referred from Kartika Hospital to the Emergency Room
at RSUD R. Syamsudin SH, Sukabumi with massive bleeding
from vagina 15 days prior to admission.
• Blood clots like the consistency of jelly.
• Recurrent bleeding, first massive bleeding happen on July
2018.
• Changes in menstrual cycle - irregular and longer.
• Feeling dizziness, weakness, fatigue, and pelvic pain since
massive bleeding occur.
• History of weight loss since September 2018.
• History of biopsy around 4 months ago.
History of Past Illness
• History of hypertension : denied
• History of diabetes mellitus : denied
• History of allergy : denied
• History of trauma : denied
• History of past surgery : denied
• History of tuberculosis : denied
Family History
• History of cancer or malignancy : denied
• History of hypertension : denied
• History of diabetes mellitus : denied
• History of allergy : denied
Menstruation History and
Contraception History
• Menarche : 11 years old
• Menstrual cycle : Irregularly, with duration of more than
7 days, dysmenorrhea (+).
• Total pads : ± 2-3 pads/day (40 – 60 cc)
• First day of LMP : -

Implant for 9 years since her last labour

Removed it on July 2018 because of the massive bleeding.
Marital History and
Gestational History
Married twice:
• Past married at 16 years old, been for 3 years and divorced.
• Second married, been for 16 years.

H Year GA Labor History Sex Current Age BW

1 1997 39 w Vaginal birth Female 22 years old 2500 gr
2 2004 Miscarriage -> abortion but not curratage
2 2005 39 w Vaginal birth Male 14 years old 2800 gr
2 2010 39 w Vaginal birth Female 9 years old 2500 gr
Physical Examination
• General condition : moderately ill
• Consciousness : compos mentis
• Blood pressure : 110/70 mmHg
• Heart rate : 110 bpm
• Respiratory rate : 21 x/minute
• Temperature : 36,1°C
• Weight : 65 kg
• Height : 160 cm
• BMI : 25.39 kg/m2  Overweight
General Examination
• Head : Normocephaly
• Skin : Pale
• Face : Simetric, deformity -
• Eyes : Anemic conjunctiva +/+, icteric sclera -/-
• Mouth : Wet oral mucosal membrane
• Ear : Deformity -/-, discharge -/-
• Neck : Struma -, tumor –
General Examination
Thorax
• Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
• Lung
• Inspection : symmetric chest expansion in both static and
dynamic breathing
• Percussion : sonor on both lungs
• Auscultation : vesicular breath sounds +/+ regular, rhonchi -/-
wheezing -/-
• Mammae : hyperpigmentation of areola +/+
nipple retraction -/-
General Examination
• Abdomen
• Inspection : convex
• Auscultation : bowel sound +, 10x/minute
• Palpation : supple in all abdominal region, tenderness –
• Percussion : tympani
• Extremities : warm, edema -/-/-/-
physiological reflex ++/++/++/++
pathological reflex --/--
Gynecologic Examination
Inspection :
bleeding (+), edema (-), ulcus (-), mass (-), condyloma (-), scar (-),
erosion (-)

Inspecullum :
• Vagina : ruggae (+), mass (-), infiltration 1/3 proximal
• Portio/Cervix : erosion (+), fluksus (-), fluor albus (-), tissue (-),
mass (+) exophytic lesion, + 7x6x5 cm
Gynecologic Examination
• Uterine Corpus : Retroflexion
• Parametrium : Supple, infiltration (-)
• Rectal Vaginal toucher : Cancer Free Space = 100% : 100%
• Pelvic examination :-
Diagnostic Evaluation
Laboratory Examination (17/02/2019, 21:38)
Test Result Normal Range
Haematology
Hemoglobin 3.9 g/dL (L) 12-15.8 g/dL
Hematocrit 14% (L) 36-48%
Leucocyte count 12,000/μL (H) 3,540-9,060/μL
Thrombocyte count 593.000/μL (H) 166,000-414,000/μL
Erythrocyte 2.3 millions/μL (L) 4.0-5.2 millions/μL
MCV 61 fL (L) 79-93.3fL
MCH 17 pg (L) 26.7-31.9 pg
MCHC 29 g/dL (L) 32.3-35.9 g/dL
Diagnostic Evaluation
Clinical Pathology Examination (18/09/2018)
Macroscopic:
Three largest tissue size 1 cm x 0.8 x 0.3 cm, smallest size 1 cm x 0.5 cm x 0.2
cm, chewy brownish white.

Microscopic:
A cervical biopsy preparation in the form of a tumor mass consisting of oval
to polygonal shape cells which grows solid hyperplasia. pleomorphic,
hyperchromatic, mitotic nucleus found. Stroma is found. Stroma is
associated with inflammatory cell lymphocytes and PMN accompanied by
dilation of blood vessels.

Conclusion: Non Keratinizing, Squamous cell carcinoma at cervix uteri

Working Diagnosis

P3A1, 38 years old, with anemia

et causa cervical cancer stage IIB
Management
• Inpatient
• Observation for vital sign (blood transfusions needed until
haemoglobin > 11 gr/dL → recheck for the haemoglobin level
after 3 bags of PRC)
• Tranexamat Acid 3 x 500 mg IV
• Cefadroxil 2 x 500 mg PO
• Ranitidine 2 x 150 mg PO
Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad bonam
C A S E A N A LYS I S
Risk Factor
Cervical Cancer
Theory Case
• HPV infection especially subtype • Multiparity: three times.
16 and 18 • Multi sexual partner: second
• Smoking marriage
• Multiparity • First intercourse before age 20:
• Multi sexual partner first marriage at 16 year old, first
• History of Combination oral child at 17 years old
contraceptive (COC) use for long
term.
• First intercourse before age 20
• Immunosuppressed
• Family history of cervical cancer.
Risk Factor
Anemia
Theory Case
• Blood loss • Massive bleeding since 15 days
• Haemolysis before admission.
• Myelosuppression
• Impaired red blood cell production
• Changes in iron metabolism
 Diagnosis - Anamnesis
Cervical Cancer
Theory Case
• Abnormal vaginal bleeding • She come because a massive
• An unusual discharge from the bleeding since 15 days prior to
vagina admission.
• Pain during intercourse. • Her period is longer and heavier
• Anemia symptoms due to chronic than usual
bleeding • Anemia symptoms
• Pelvic pain or lower abdomen in • Pelvic pain
pelvic inflammation • Weight loss
• Lower waist pain due to
hydronephrosis
• Weight loss
• Foot edema
• Bowel and urination disorders
 Diagnosis - Anamnesis
Anemia
Theory Case
• Syncope • Abnormal menstruation and
• Exercise dyspnea massive bleeding
• Headache/Vertigo • Dizziness / vertigo
• Chest pain • Weakness / syncope
• Fatigue (disruptive to work and • Fatigue
daily activities)
• Abnormal menstruation in female
patients
• Pallor may be apparent
 Diagnosis – Physical Examination
Cervical Cancer
Theory Case
• Inspecullum: the cervix enlarges, the Vagina: infiltration 1/3 proximal
surface of the portio is uneven,
reddish, carcinomatous or Portio/Cervix: erosion (+), mass (+)
ulcerative, and easily bleeds exophytic lesion, + 7x6x5 cm
• Bimanual examination: palpable
enlarged exophytic or endovytic Rectal Vaginal toucher: Cancer Free
cervix, easily bleed, with the Space = 100% : 100%
possibility of palpable invasion of
the vagina
• Retrovagina examination,
infiltration of tumor masses in
parametrium and sacrouterine
ligament.
 Diagnosis – Physical Examination
Anemia
Theory Case
pale or yellowish skin, conjunctiva, Pale skin
tongue, palms and nailbed are pallor. Conjungtiva anemis/pallor
 Diagnosis – Diagnostic Evaluation
Cervical Cancer
Theory Case
Biopsy Biopsy
Squamous cell carcinoma or Non Keratinizing, Squamous cell
Adenocarcinoma carcinoma at cervix uteri
 Diagnosis – Diagnostic Evaluation
Anemia
Theory Case
Laboratorium Laboratorium
The laboratory values obtained on the Blood count result
blood count and peripheral smear Hb 3.9 g/dL
Hb < 12g/dL MCV 61 fL
Microcytic – MCV <80fL
Normocytic – MCV 80-100fL
Macrocytic- MCV >100fL
 Management
Cervical Cancer
Theory Case
• external beam and brachytherapy Refer to obstetric and gynecology
radiation specialists.
• concurrent cisplatin-based
chemotherapy. Refer to hospitals that can provide
treatment.
 Management
Anemia
Theory Case
Treatment et causa Inpatient
Iron supplement Observation for vital sign
Blood Transfusion if Hb<6g/dL Blood Transfusion until Hb > 11g/dL
Tranexamat Acid 3 x 500 mg IV
Cefadroxil 2 x 500 mg PO
Ranitidine 2 x 150 mg PO
Iron supplement take home medicine
THANK YOU
REFERENCES
1. NCI Dictionary of Cancer Terms [Internet]. National Cancer Institute. 2011 [dikutip 22 Februari 2019]. Tersedia pada:
https://www.cancer.gov/publications/dictionaries/cancer-terms
2. WHO | Cervical cancer [Internet]. WHO. [dikutip 22 Februari 2019]. Tersedia pada:
http://www.who.int/cancer/prevention/diagnosis-screening/cervical-cancer/en/
3. Kemenkes RI. Panduan penatalaksaan kanker serviks. 2011.
4. Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Williams gynecology. 3 ed. United States:
McGraw-Hill Education.; 2016. 657-675 hal. (Cervical Cancer).
5. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynecol Obstet. Mei
2009;105(2):103–4.
6. Beckmann CRB, American College of Obstetricians and Gynecologists, editor. Obstetrics and gynecology. 6th ed.
Baltimore, MD: Lippincott Williams & Wilkins; 2010. 375-387 hal.
7. Dreyer G, Mostert AE, Visser C, Mouton A. The severity and optimal management of iron deficiency and anemia before
radiation for cervical cancer at the University of Pretoria Academic Hospitals. South Afr J Gynaecol Oncol. 2 Januari
2017;9(1):11–5.
8. Conrad ME. Anemia. In: Walker HK, Hall WD, Hurst JW, editor. Clinical Methods: The History, Physical, and Laboratory
Examinations [Internet]. 3rd ed. Boston: Butterworths; 1990. Tersedia pada:
http://www.ncbi.nlm.nih.gov/books/NBK254/
C E RV I C AL C A NCE R
ANATOMY
ANATOMY
ANATOMY
ANATOMY
STAGING
STAGING
Introduction – Cervical Cancer
Three types of cervical cancers:
• Squamous cell carcinomas
• Adenocarcinomas
• Adenosquamous carcinoma/mixed carcinomas.
Introduction
Risk factors:

• Multiparity
• First intercourse before age 20
• Immunosuppressed
• Family history of cervical
cancer.
Introduction
Sign & Symtoms:

• An unusual
discharge from the
vagina
• Anemia symptoms
due to chronic
bleeding
• Foot edema
• Bowel and
urination disorders
Introduction
Sign & Symptoms:
• Inspecullum:
• the cervix enlarges
• the surface of the portio
is uneven, reddish,
carcinomatous or
ulcerative, and easily
bleeds.
Introduction
Sign & Symptoms:
• Bimanual
examination:
• palpable enlarged
exophytic or
endovytic cervix
• easily bleed
• with the possibility
of palpable invasion
of the vagina.
Introduction
Sign & Symptoms:
• Rectovagina examination:
infiltration of tumor masses
in parametrium and
sacrouterine ligament.
Introduction
STAGING
STAGING - IA
STAGING - IB
STAGING - II
STAGING - IIIA
STAGING - IIIB
STAGING - IVA
STAGING - IVB
Introduction – Cervical Cancer
Management:

SURGERY RADIATION CHERMOTHERAPHY

THERAPY
A N E MI A
Introduction – Anemia
Definition :
A reduction in red cell mass below the requirement to
deliver the oxygen demand of the tissues. Anemia in women
as an Hb < 12 g/dl.
Introduction – Anemia
Epidemiology :

Prevalent in

30% to 90%
of patients with cancer.
Introduction – Anemia
Grading and classification of anemia :

Normal Mild Moderate

(> 11 g/dL) (9.5-10.9 g/dL) (8.0-9.4 g/dL)

Extremely
Severe Severe
(6.5-7.9 g/dL)
(< 6.5 g/dL)
Introduction – Anemia
Sign and Symptoms:
Introduction – Anemia
Diagnostic Evaluation :
Introduction – Anemia
Management: