During a routine physical examination of a 35-year-old Asian female, you note a right adnexal fullness. She has had no symptoms of pain or bloating and has been menstruating normally. Her menses occur approximately every 30 days and her next period is expected to occur in 1 week. Pelvic ultrasonography reveals a thin-walled simple cyst 5 cm in diameter. No other abnormalities are seen in the pelvic structures.
Which one of the following is the best course of management for this condition?
Correct Answer C:
Adnexal masses in women under 45 years of age are benign in 80%-85% of cases. The specific findings of this case also strongly suggest a benign etiology, namely a thin-walled, simple cyst, a lesion that is less than 8 cm in size, and a patient of relatively young age. No aggressive means are indicated in these situations unless there are significant clinical symptoms such as pain, abdominal pressure, urinary symptoms, or gastrointestinal symptoms. Most experts currently recommend a conservative approach with repeat ultrasonography in at least 2 months, during which time the vast majority of benign cysts resolve spontaneously.
Which of the following statements concerning the diagnosis of an adnexal mass is false?
Correct Answer B: Adnexal masses can be found in all age groups, though there are differences in the prevalence of certain conditions based on the patient’s age. After menopause, the ovaries become nonpalpable, so any enlargement should make one suspicious for cancer. In the reproductive age, functional cysts are common. These can be up to 6 cm or more, so any simple cyst less than 6 cm can be observed for several cycles. If still present, a workup is indicated.
A. Various etiologies for adnexal masses have different incidences depending on the patient’s age. Germ cell neoplasms are more likely to be found in younger women. Ectopics will be found only in reproductive age women. Epithelial malignancies are more common in postmenopausal women.
C. See answer to A.
D. In postmenopausal women, an adnexal mass should be considered malignant until proven otherwise, Any adnexal mass, cystic or solid, in a postmenopausal woman requires immediate preparation and surgical removal.
E. Any solid mass of the ovary needs to be evaluated to rule out a malignancy.
The treatment of choice for thrombotic events in the antiphospholipid antibody syndrome is:
Correct Answer E:
Treatment of the initial thrombosis in patients with the antiphospholipid antibody syndrome does not generally differ from treatment of patients with the same disorder who do not have the antiphospholipid antibody syndrome. Anticoagulation with heparin and then subsequently with oral anticoagulation is initiated. The duration of anticaogulation in patients without the antiphospholipid antibody syndrome is generally 3-6 months. In patients with the antiphospholipid antibody syndrome, the risk of recurrence is relatively high for both arterial and venous thrombotic events. As a result, patients are generally started on long-term (in some cases life-long) oral anticoagulation.
The treatment of women who are pregnant and have the antiphospholipid antibody syndrome can result in a much higher success rate for the pregnancy. Several regimens have been studied including heparin.
The antiphospholipid syndrome in women is commonly associated with:
Women with antiphospholipid antibodies, including lupus anticoagulant and anticardiolipin antibodies, are at significant risk for adverse pregnancy outcome. In primary antiphospholipid syndrome (APS), fetal loss is reported to be between 50% and 75%. Recurrent spontaneous abortion, particularly in the second trimester, is one of the most consistent features of this syndrome. Other pregnancy-related complications include intrauterine growth retardation, placental abruption, preeclampsia, and premature delivery. Dysmenorrhea, metrorrhagia, and amenorrhea are not commonly associated with this condition. A false-positive test for syphilis does not fulfil the laboratory criteria for the diagnosis of APS, and patients with APS are not known to be at increased risk for syphilis.
A 29-year-old white female is hospitalized following a right middle cerebral artery stroke confirmed by MRI. Her past medical history is remarkable only for a history of an uncomplicated tonsillectomy during childhood and a second trimester miscarriage 3 years ago.
The only remarkable finding on physical examination is left hemiplegia. The initial laboratory workup reveals normal hematocrit and hemoglobin levels, a normal prothrombin time, and a platelet count of 200 x 109/L. The activated partial thromboplastin time is 95 sec (N 23.6-34.6), and it does not normalize when the patient’s serum is mixed with normal plasma. A serum VDRL is positive, and a serum FTA-ABS is nonreactive.
Which one of the following is the most likely diagnosis?
The antiphospholipid syndrome (choice C) is due to the appearance of a heterogeneous group of circulating antibodies to negatively charged phospholipids, including most commonly a lupus anticoagulant and anticardiolipin antibodies. The antibodies are usually detected by a false-positive serologic test for syphilis. Clinical features include venous and arterial thrombosis, fetal wastage, thrombocytopenia, and the presence of an activated partial thromboplastin time (aPTT) inhibitor. It is an important diagnostic consideration in all patients with unexplained thrombosis or cerebral infarction, particularly in young patients.
→ Although hemophilia (choice A) would also be associated with a prolonged aPTT, the PTT would normalize when the patient’s serum was mixed with normal plasma.
→ Neurosyphilis (choice B) is excluded by the negative serum FTA-ABS result.
→ Thrombotic thrombocytopenic purpura (choice D) is not associated with prolongation of the aPTT and is associated with a hemolytic anemia.
→ Although protein C deficiency (choice E) is a hypercoagulable state that can lead to stroke, none of the laboratory abnormalities suggests this diagnosis.
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