Cervical cancer is the second most common cancer among women in the world, with about 500,000 cases diagnosed each year. Factors associated with the development of cervical cancer include lack of screening, early sexual intercourse, multiple sexual partners, early pregnancy, oncogenic subtype of HPV, cigarette smoking, and immunocompromised status (Shingleton & Orr, 1995).
One of the first symptoms of cervical cancer is likely to be a thin, blood-tinged vaginal secretion that is not readily noticed by the patient. As the malignancy increases, the abnormal bleeding becomes more readily obvious, more frequent, and lasts longer (Evans-Jones, 2005; DiSaia & Creasman, 2002).
Hemorrhage as a result of cervical cancer is associated with erosion of the cervical surface, which can progress to tissue necrosis. Cancer cells (squamous type [85% to 90%], adenocarcinoma [10% to 20%], and adenosquamous carcinoma) initiate increased vascularity of the cervical microcirculation, and sustained growth occurs as a result of angiogenesis. Subsequent infiltration and expansion of the tumor mass occurs, including to nearby formed blood vessels that supply the tumor with nutrients and oxygen. As more cervical tissue is invaded, the new branching vessels, which arise in the cervical stroma, are pushed to the surface. This makes the contour of the cervix irregular and friable as surface epithelium is lost. Ulceration and exophylic or endophylic lesions then occur.
Ulcerative lesions create a defect of loss of intercellular cohesiveness in the cervix or upper vagina; exophylic lesions protrude from the cervix and replace it; and endophylic lesions protrude from the endocervix. As the tumor becomes more bulky and neovascularization increases, the risk of hemorrhage increases. The end result is increased vascular capillary supply and increased friable and erosive cervical surfaces with large collateral branches of arterial networks, which cause hemorrhage. When the bleeding is chronic, weight loss, extreme fatigue, and anemia occur. Anemia increases hypoxia of cervical carcinomas, which increases iron deprivation, inflammatory reactions, and infections (Marchal et al., 2005) and negates healing. The importance of consistent gynecologic care, including Papanicolaou (PAP) smears, cannot be overstated. PAP smears can detect preinvasive conditions of the surface layers of the cervix before the basement membrane is invaded, increasing the likelihood of cure, survival, and a good quality of life. Preinvasive diagnoses include cervical intraepithelial neoplasia (CIN) and squamous intraepithelial lesions (SILs).
EPIDEMIOLOGY AND ETIOLOGY
The amount of bleeding is directly related to the stage of disease and necrosis of the cervical tumor. The incidence of blood loss greater than 1000 mL during surgery is0.8% (Cao, 2001); with radical surgery of invasive cervical carcinoma, the incidence is 4.1% (Sliwinski et al., 2003). Although hemorrhage secondary to cervical cancer is rare, it usually is associated with bulky tumor necrosis and advanced stage disease (Bowcutt et al., 2007; Rosenkoetter et al., submitted, 2007). The disease is preceded by a period of cellular abnormality, and whether of low or high grade, these abnormalities are amenable to detection with routine exfoliative sampling by PAP smear (Yoder & Rubin, 1992). The main factor that correlates with development of late-stage disease is absence of routine gynecologic examinations, including a PAP smear, for longer than 5 years. For further validation, a colposcopic examination is conducted (Wiggins et al., 1995). Cigarette smoking is known to increase the cellular incidence of high-grade cervical cancer lesions, and smoking cessation is a necessary intervention of patient care.
RISK PROFILE
• Smoking significantly increases the incidence of high-grade lesions (dos Santos et al., 2004).
• History of abnormal PAP smear, cervical dysplasia or cervical cancer, or squamous cell carcinoma is the most common historical finding, followed by adenocarcinoma (Shintaku et al., 2000), adenosquamous carcinoma, and neuroectodermal tumors (Malpica & Moran, 2002), and lymphoma (Chan et al., 2005).
• Anemia with hemoglobin less than 12g/dL (Marchal et al., 2005).
• As tumor size increases, so does the risk for hemorrhage, especially in FIGO stage III tumors (Sobiczewski et al., 2002).
• Postcoital bleeding (Abu et al., 2006; Jha & Sabharwal, 2002); 11% to 19% of cases are diagnosed as cervical cancer, and 4% are invasive cancer (Rosenthal et al., 2001).
• Factor XI deficiency, primarily in females of Ashkenazi Jewish descent (Kim et al., 2004).
• History of endometrial polyps (Selo-Ojeme et al., 2004); 6.8% are diagnosed with cervical cancer.
• Environmental factors, such as lack of insurance coverage (Edelman & Adams, 2004) and lower socioeconomic status.
• Medications: Anticoagulants (heparin, warfarin, ticlopidine, clopidogrel bisulfate [Plavix], aspirin, ibuprofen) and other NSAIDs inhibit platelet aggregation and prolong bleeding time. Herbal medications known to increase bleeding include astragalus root, bilberry, bromelain from pineapple stem, capsicum, cayenne, chamomile, coleus, dong quai, evening primrose, feverfew, flaxseed oil, garlic, ginger, gingko, American ginseng, green tea, hawthorn, horse chestnut, kava kava, licorice, meadowsweet, motherwort, passionflower, poplar, red clover, shepherd’s purse, and tumeric; vitamins and supplements include chondroitin, fish oil, and vitamin E (Wren & Norred, 2003).
PROGNOSIS
Control of hemorrhage secondary to cervical cancer through the use of surgery and/or external radiation is successful in 95% of cases. Recurrence of bleeding occurs in 5% of cases, and 3% have uncontrolled bleeding (Sliwinski et al., 2003). Embolized patients have poorer disease-free survival (Kapp et al., 2005). The risk of ovarian metastasis is low for patients with squamous cell carcinoma of the cervix stages IA and IB (L’ubusky et al., 2004). Adenocarcinoma with metrorrhagia has a 5-year survival rate of 68% (Chargui et al., 2006); poor prognostic factors include age over 50 years, tumor larger than 4 cm, later stage, higher tumor grade, and lymph node involvement.
PROFESSIONAL ASSESSMENT CRITERIA (PAC)
For a quick glance at assessment criteria, see Table 20-1.
1. Assess for vaginal bleeding every 15 minutes × 4, then every 1 hour × 24 hours.
2. Assess for intravenous access with at least one 22-gauge catheter.
3. Assess for signs of hypovolemia (CVP less than 8 cm H2O, tachycardia, hypotension with systolic pressure less than 90 mm Hg, urine output less than 30 mL/hr, Hct less than 30%) every 15 minutes × 2, then every 1 hour × 8 hours.
4. Assess skin: Cold, clammy, diaphoretic, pale.
5. Assess laboratory values: CBC, including Hgb and Hct, chemistry panel for hypokalemia, increased PT/PTT, INR.
6. Pulse oximetry every 1 hour and ABGs as prescribed.
7. Vital signs: Decreased or increased temperature; decreased blood pressure; increased pulse or tachycardia; increased respiratory rate, which may be accompanied by SOB and tachypnea; increased pain.
9. Assess for sociologic, cultural, or religious barriers to potential blood transfusions.
10. Assess diagnostic test results: CT pelvic scan for obstruction, lymphadenopathy, or metastasis and CXR for lung metastasis.
11. Assess for fatigue as a sign of anemia, anxiety as a sign of sepsis, and confusion as a sign of hypoxia or sepsis.
12. Assess for adequate renal function by serum creatinine values and hourly urine output values.
13. Assess plasma value of soluble urokinase plasminogen activator receptor (suPAR), as it should be greater than 0.9 mcg/L (Piironen et al., 2006; Riisbro et al., 2001).
| Indicator | Assessment |
|---|---|
| Vital signs | |
| Temperature | Subnormal or normal |
| Pulse | Tachycardia >100 bpm, weak, thready |
| Respirations | Increased, SOB, tachypnea |
| Blood pressure | Decreased systolic <90 mm Hg (torr) |
| Pain | >5 on 1-10 scale |
| CVP | Decreased <8 or >15 |
| History | |
| Symptoms, conditions | Lack of routine gynecologic care for longer than 5 years |
| Previously untreated abnormal PAP smear | |
| Did not receive HPV vaccine | |
| Irregular, intermenstrual, postcoital bleeding | |
| Heavier menses | |
| Underlying coagulopathy | |
| Factor XI deficiency in females of Ashkenazi Jewish descent | |
| Increased used of medications or herbals that increase bleeding | |
| Signs and symptoms | Agitation; anxiety; cold, clammy skin; confusion; diaphoresis; disorientation; fear; pallor; profuse vaginal bleeding; fatigue |
| Laboratory values | Hct & Hgb decreased |
| Serum potassium decreased | |
| PT, PTT, or INR increased | |
| Diagnostic tests | Cervical biopsy confirms carcinoma. |
| Pelvic examination positive (may need to be performed under anesthesia). | |
| Cystoscopy and/or proctoscopy to evaluate for bladder and bowel invasion. | |
| Chest x-ray film indicates lung metastasis. | |
| CT scan of abdomen/pelvis indicates obstruction, lymphadenopathy, and/or metastasis and is used to plan for radiation therapy. | |
NURSING CARE AND TREATMENT
Treatment involves surgery, chemotherapy, radiation therapy, medications, or usually a combination of these. Chemotherapy may include radiosensitization with 5-fluorouracil, cisplatin, or hydroxyurea. External beam radiation to the pelvis may be provided in daily fractions of 300 to 400 cGy for 3 to 4 days, followed by decreased daily fractions of 180 to 200 cGy to maximum dose, to help promote tumor shrinkage and damage to hemorrhagic surface blood vessels. Treatment usually is administered over 5 to 6 weeks and is followed by brachytherapy. Medications are given to treat anemia, volume deficit, infection, and/or hypoxemia (Table 20-2).
1. Placement of a triple lumen intravenous catheter to allow monitoring of CVP and administration of blood products, fluids, and medications (e.g., antibiotics, vasopressors) as prescribed.
2. Placement of a Swan-Ganz catheter for monitoring of cardiovascular status for potential hypovolemic or septic shock.
3. Prepare for vaginal packing or arterial embolization.
4. Insert Foley catheter.
5. Vital signs every 15 minutes × 2, then every 1 hour × 8 hours.
6. I&O every 4 hours.
7. STAT blood work: CBC, Chem-18, PT/PTT, INR, type and crossmatch, ABGs, blood cultures.
8. Oxygen per nasal cannula to maintain oxygen saturation greater than 90%.
9. Monitor for fluid overload: CVP greater than 15 cm H2O, increased blood pressure, jugular vein distention, bilateral peripheral edema, dyspnea, tachycardia, rales.
10. STAT radiation therapy consult.
11. Monitor for signs and symptoms of sepsis or toxic shock syndrome: CVP less than 8 cm H2O, tachycardia, decreased blood pressure, increased or decreased temperature, oxygen desaturation, confusion, agitation.
| Medication | Rationale |
|---|---|
| Intravenous solutions | Isotonic, crystalloid, and colloid solutions used to treat hypovolemia |
| Vasopressors | Used to treat hypotension |
| Oxygen | Used to treat hypoxemia secondary to anemia and/or blood loss |
| Packed RBCs | Transfusion to maintain Hct >30% and to maximize oxygenation |
| Fresh frozen plasma or vitamin K | Transfusion or vitamin K to correct coagulopathy |
| Antibiotics | Broad-spectrum antibiotics to treat infection, sepsis, or toxic shock syndrome |
| Colony-stimulating factors (CSFs) | Erythropoietin to manage anemia (Marchal et al., 2005) |
EVIDENCE-BASED PRACTICE UPDATES
1. Increased endometrial thickening greater than 5 mm, seen in ultrasound, often is overestimated by ultrasound and is not a reliable indicator of cervical cancer, as was once thought (Saha et al., 2004).
2. Although younger women are less likely to develop cervical cancer, women younger than 35 years old have a median time to diagnosis of 9 months; women older than 35 years old have a median time to diagnosis of 2 months (Yu et al., 2005). Younger women who have symptoms suspicious for cervical cancer should be more extensively evaluated.
3. The laparoscopic radical vaginal approach is superior to abdominal radical hysterectomy type II for cervical cancer stages I to III (Malur et al., 2001), and it has a lower rate of blood transfusions, blood loss, and postoperative morbidity.
4. Radical trachelectomy with pelvic lymphadenopathy in stage I cervical cancer involves an estimated blood loss of 203 mL (Schlaerth et al., 2003) and is a feasible treatment to preserve fertility.
5. Many treatments are successful in reducing blood loss (Taylor & Magos, 2006), including medications, laser treatment, surgery, and other procedures (Box 20-1).
BOX 20-1
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SUCCESSFUL TREATMENTS TO REDUCE BLOOD LOSS IN HEMORRHAGE SECONDARY TO CERVICAL CANCER
• Vasopressin administered perioperatively (Martin-Hirsch & Kitchener, 1999)
• Bilateral internal iliac artery ligation (BIIAL) (Gharoro, 2003; Cao, 2001)
• Triple tourniquet technique with open myomectomy (Hatremi et al., 2005)
• Transarterial embolization (Hatremi et al., 2005)
• Embolization or ligation of hypogastric artery (Yalvac et al., 2002)
• Thumbtack to control presacral venous hemorrhage (Harma et al., 2005)
• High-dose ratio cervical ring applicator (Grigsby et al., 2003)
• Cauterization of cone bed (superior to sutures) (Kamat et al., 2004)
• Laser conization (dos Santos et al., 2004)
• Radiofrequency bipolar coagulator therapy (Ercoli et al., 2003)
• Intraabdominal packing with removal of packing in 6 days (Cirese & Larciprete, 2003)
• Vaginal gauze packing (Kim et al., 2002)
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