Download Question 2 : FT

Case 1250: Obstetrics and Gynaecology SAQs
Authors and Affiliations
Hannah Pham
School of Medicine
University of Adelaide
Associate Professor Paul Duggan
Head, Discipline of Obstetrics and Gynaecology, University of Adelaide
Head of Unit (Gynaecology),
Chair, MBBS Assessment Committee
Dr Sarah Cash
Gynaecological Registrar
Royal Adelaide Hospital
These Short Answer Questions have been prepared for those planning on sitting their End of Year
Examinations.
Case Overview
Learning Objectives
Question 1 : FT
Question Information:
A 55-year-old post-menopausal woman has been referred to a gynaecology clinic for management of a
right ovarian mass found on transvaginal ultrasound. This was performed in the setting of vaginal
bleeding and weight loss. A recent Pap smear was normal. The report reads: "There is an 8cm right
ovarian complex cyst with solid components, multiple locules and papillary projections"€ •. Her
CA125 is 80U/mL (N <35).
Question:
What investigation is most appropriate now? (1 mark) Justify your answer. (2 marks)
Choice 1: null Score : 0
Choice Feedback:
Answer
CT chest/abdomen/pelvis (1)
Justification
This
ovarian mass is very likely to be malignant. (0.5 marks) This observation is based on the overall
picture - a high CA125, postmenopausal age, and complex ultrasound features summarised by a very
high Risk of Malignancy Index *. (0.5 marks)
A
CT chest/abdomen/pelvis is required for preoperative staging (0.5 marks) and to exclude primary
malignancy concurrent with ovarian metastases (Krukenberg tumour) (0.5 marks).
Notes
The
result of the CT chest/abdomen/pelvis may influence who performs the laparotomy (for example,
bowel or breast primary with ovarian metastases), and may also necessitate other investigations prior to
laparotomy (eg, colonoscopy). Imaging will also assess for bulky disease, which may influence use of
chemotherapy prior to primary surgery. This usually requires a tissue diagnosis first †“ as might be
obtained by CT guided needle biopsy
The
RMI in this case is 720 †“ it is the product of the CA125 value, a score of 3 for complex
ultrasound features, and a score of 3 for post-menopausal state. Students would not be expected to
calculate this but to understand the principles behind it.
Question 2 : FT
Question Information:
A 48-year-old woman, G3P3 (all normal deliveries), presents to her General Practice concerned about
her periods. They are still regular but have become heavier over the last two years. She describes
"flooding" and the use of "twice as many pads"€ • as she did in her youth. There is no
intermenstrual bleeding nor abnormal discharge. Her last menstrual period was two weeks ago. She
denies pelvic heaviness, weight loss, anorexia, or fatigue. She is sexually active and uses condoms for
contraception. She denies any family history of cancer.
On examination, her pulse rate is 88/min, blood pressure 100/50mmHg, respiratory rate 14/min, and
temperature 36.5C. Her chest is clear on auscultation, heart sounds are dual with a soft systolic
murmur. The abdomen is soft, non-tender, and no masses are palpable. Bimanual and speculum
examinations are unremarkable.
Her investigation results are as follows:
Pap
smear (12 months ago): normal
Complete
Iron
blood examination: Haemoglobin 80g/L [115-155], Mean cell volume 78 fL [80-98]
studies: ferritin <5 mcg/L [25-155], serum iron 5.3mcg/dL [14-32], serum transferrin 4.6g/L [14-
32]
Beta
HCG (serum): negative
Urine
dipstick: negative
Pelvic
Ultrasound Scan demonstrates endometrial thickness of 9mm. There is a well-defined,
hypoechoic lesion likely to represent a 3cm intramural fibroid.
Question:
In addition to treating her iron deficiency, what management is most appropriate now? (1 mark) Justify
your answer. (1 mark)
Choice 1: null Score : 0
Choice Feedback:
Answer
Endometrial biopsy (1)
Justification
Although
her risk is small and ultrasound has demonstrable pathology that accounts for her bleeding,
she should undergo further investigation with outpatient hysteroscopy and endometrial sampling to
exclude endometrial pathology such as polyps and malignancy. The latter is less likely given her premenopausal state (1)
Notes
Insertion
of Mirena at the time of outpatient hysteroscopy and endometrial sampling would be
appropriate management that would also be the most cost-effective approach. She has had three
normal vaginal deliveries, which usually makes for ease of insertion in a clinic setting.
It
is possible this woman is perimenopausal, has an anovulatory condition, or a benign endometrial
lesion.
Question 3 : FT
Question Information:
A 33-year-old woman who is G3P3 is reviewed on a domiciliary home visit day 12 post-partum. She had
an uncomplicated pregnancy and delivered a healthy baby girl via normal vaginal delivery.
She has had good breast milk production, feeding from both breasts alternately. Over the past two days
there has been increasing pain in her left breast. She has continued to express milk from the left breast.
She denies dysuria, abdominal pain, or change in the appearance/smell of her lochia.
On examination, her pulse rate is 115/min, blood pressure 110/70mmHg, respiratory rate 19/min, and
temperature 38.3C.
The left breast is swollen with erythema over the lateral aspect, which is warm on palpation. There is a
clear/white nipple discharge. The right breast has a normal appearance.
Question:
What is the most appropriate advice regarding breast-feeding from the left breast? (1 mark) Justify your
answer. (1 mark)
Choice 1: null Score : 0
Choice Feedback:
Answer
Continue to breast-feed (1)
Justification
The
patient likely has a mastitis of the left breast. (0.5)
Breast-feeding
should be continued as milk stasis contributes to infection. (0.5)
Notes
The
milk content in mastitis or even in an abscess is safe for the infant. The infant†™s feeds should
not be changed. The infection will not be †œpassed on†• or transmitted to the infant and mothers
should be reassured about this.
Unless
the pain of breast-feeding is too great, she should be encouraged to continue breastfeeding;
alternatively expressing breast-milk can be encouraged.
Question 4 : FT
Question Information:
A 24-year-old who is G1P0 presents to the Emergency Department at 13 weeks gestation (singleton
pregnancy) with nausea and severe vomiting. She has vomited six times in the past six hours, and is
unable to keep any fluid down. She feels dizzy and unsteady on her feet. She denies dysuria, fever,
abdominal pain, or diarrhoea. She was well prior to these vomiting episodes. She has no known past
medical history and takes no regular medications.
On examination, her pulse rate is 110/min, blood pressure 90/50mmHg, respiratory rate 18/min, and
temperature 36.9 degrees C. Her oxygen saturation is 99% on room air. Her chest is clear on
auscultation, heart sounds dual with no murmurs. Her abdomen is soft and non-tender.
Urine
dipstick analysis: negative nitrites, negative leucocytes, negative blood, ketones +++.
Complete
blood examination, including White cell count: normal
Biochemistry:
Na 145 mmol/L [137-145], K 4.0 mmol/L [3.5-4.9], Creatinine 50 [53-115]. Liver
function tests normal
Thyroid
Blood
function tests normal
glucose level 4.0 mmol/L
Cardiotocograph:
fetal heart auscultated HR 145/min
Question:
What immediate treatment does she require? (1 mark) Justify your answer. (2 marks)
Choice 1: null Score : 0
Choice Feedback:
Answer
Resuscitation with intravenous fluids (1)
Justification
The
patient is likely suffering from hyperemesis gravidarum. (1) This is a diagnosis of exclusion.
Diagnoses to consider include urinary tract infection (unlikely as the dipstick analysis is normal and she
denies urinary symptoms), appendicitis, cholecystitis (unlikely as she denies abdominal pain), and
thyrotoxicosis (excluded by normal thyroid function tests).
The
diagnosis of hyperemesis gravidarum is supported by the presence of ketones in the urine in the
presence of a normal BGL.
Provided
her airway is secure and breathing is normal, resuscitation with intravenous fluids is the
most appropriate immediate treatment. The patient is tachycardic and hypotensive, which reflects
significant dehydration. (1) Her sodium level is 145mmol/L (on the upper limit of normal) which also
reflects dehydration.
Question 5 : FT
Question Information:
An 18-year-old woman G1P0 at 10 weeks†™gestation presents to the Emergency Department with
lower abdominal pain associated with nausea and vomiting. Her last menstrual period was 10 weeks
ago but she reports vaginal bleeding today associated with her pain. A dating ultrasound scan was
performed several days ago.
On examination, her pulse rate is 90/min, blood pressure 120/70mmHg, respiratory rate 18/min, and
temperature 36.8C.
The abdomen is not rigid and there is no guarding. She is tender in the suprapubic region. On speculum
examination, the cervical os is widely open but no products of conception are visible. A bedside
transabdominal ultrasound demonstrates an intra-uterine pregnancy, fetal heartbeat visible, and no
other visible masses.
The urinalysis is negative.
Question:
What is the most likely diagnosis? (1 mark) Justify your answer. (2 marks)
Choice 1: null Score : 0
Choice Feedback:
Answer
Inevitable miscarriage (1)
Justification
The
patient has likely suffered an inevitable miscarriage. She is in the first trimester of pregnancy
presenting with bleeding and abdominal pain, which makes ectopic pregnancy and miscarriage the
most important differential diagnoses to consider. (1)
The
bedside ultrasound, although imperfect and susceptible to great inter-observer variability, has
demonstrated an intra-uterine pregnancy, and is consistent with her recent dating ultrasound scan.
Coupled with an open cervical os and PV loss, an inevitable miscarriage is the more likely diagnosis
compared to ectopic pregnancy. (1)
Notes
If
products of conception were visible, the diagnosis would be of an incomplete miscarriage.
Question 6 : FT
Question Information:
A 15-year-old girl presents to your clinic seeking the oral contraceptive pill. She has been sexually
active with her 15-year-old boyfriend for the last three months. You counsel her regarding safe sex
practices but also Pap smear screening.
Question:
What is the most appropriate recommendation to her regarding Pap smear screening? (1 mark)
Choice 1: null Score : 0
Choice Feedback:
Answer
Pap smear at 18 years old, then every 2 years (1)
Notes
The
current NHMRC cervical cancer screening guideline states that all women who have ever been
sexually active should start having Pap tests between age 18 and 20 years, or 1-2 years after first
having sexual intercourse, whichever is later.
The
updated National Cervical Screening Program will commence on 1 May 2017 will replace the
current cytology-only Pap test for cervical screening. This will invite women aged 25 to 74 years, both
HPV vaccinated and unvaccinated, to undertake a combined Pap and HPV test every 5 years. Women
of any age who have symptoms (including pain or bleeding) should have appropriate clinical
assessment, which may include a cervical cytology test and an HPV test.
An
HPV test every five years is more effective at protecting against cervical cancer and is just as safe
as, screening with a Pap test every two years.
References
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/future-changes-cervical
Question 7 : FT
Question Information:
An 18-year-old woman presents to your clinic requesting contraception. She is sexually active and
currently uses condoms for contraception. She does not wish to conceive for at least three years. Her
last menstrual period was two weeks ago. Her periods are regular and last for five days. She
experiences dysmenorrhea at the beginning of her cycle, with good relief from ibuprofen. She has never
been pregnant. Her only medical condition is inflammatory bowel disease (IBD), for which she takes
sulfasalazine and corticosteroids during flare-ups. She is a non-smoker.
Question:
What is an appropriate contraceptive choice for this woman? (1 mark) Justify your answer. (2 marks)
Choice 1: null Score : 0
Choice Feedback:
Answer
Etonogestrel implant (Implanon) (1)
Justification
This
woman†℠¢s IBD can affect systemic absorption of oral contraceptives, so non-oral
choices are most appropriate. (1)
Given
her wish to not conceive for at least three years, an Implanon implant is an appropriate choice.
As she is nulliparous, the levonorgestrel-IUCD (Mirena) is less appropriate though an alternative if
Implanon is not acceptable. Depo-Provera is also an option but is less preferred as it cannot be stopped
or removed if intolerable side effects occur that warrant discontinuation of therapy, and prolonged use is
associated with a delayed return of menses on cessation of the regimen. (1)
Oral
contraceptives may be considered if the other alternatives are not suitable, but at a slightly
higher dose.
Question 8 : FT
Question Information:
A 25-year-old woman presents to her General Practitioner regarding a three day history of foul-smelling
vaginal discharge. Her menstrual period was last week. A speculum examination reveals a creamy-grey
discharge and a sterile swab is taken. The swab is smeared onto a slide for microscopy, which shows
clue cells. The vaginal pH is 5.0. A fishy odour is present on addition of 10% potassium hydroxide to the
vaginal fluid.
Question:
What is the most appropriate treatment for her condition? (1 mark) Justify your answer. (1 mark)
Choice 1: null Score : 0
Choice Feedback:
Answer
Metronidazole (1)
Justification
Bacterial
vaginosis is the most likely cause for this woman's presentation, and is supported by the
findings of elevated vaginal pH, fishy odour, clue cells, and a creamy-grey discharge (the AMSEL
criteria). (0.5)
Bacterial
vaginosis occurs due to an increase in anaerobic species (for example, Gardnerella
vaginalis) with simultaneous reduction in lactobacilli. Thus, an agent effective against anaerobes would
be most appropriate (0.5)
AMSEL
criteria is met when at least 3 out of 4 of the following are present
1. Vaginal pH >4.5
2. Presence of clue cells in vaginal fluid
3. Milky, homogenous vaginal discharge
4. Release of amine (fishy) odour after addition of 10% potassium hydroxide to the vaginal fluid
Question 9 : FT
Question Information:
A 30-year-old woman presents to a rural hospital at 33 weeks gestation concerned she might be going
in to labour. She is G2P1. Her last delivery occurred vaginally at 35 weeks. She complains of
intermittent, colicky lower abdominal pain. Her pregnancy has been uncomplicated thus far, apart from
ongoing smoking.
On vaginal examination the cervix is posterior, of medium consistency, 30% effaced, 2cm dilated,
station -2. Her Bishop score is 5. Swabs for Group B streptococcus are taken. There is no amniotic fluid
visible at speculum examination and an Amnicator test is negative.
Question:
What screening investigation was most likely to have been helpful in determining this woman's
likelihood of establishing in labour within the next seven days? (1 mark) Justify your answer. (2 marks)
Choice 1: null Score : 0
Choice Feedback:
Answer
Fetal fibronectin test taken by high vaginal swab prior to digital vaginal examination (1)
Justification
Fetal
fibronectin is a glycoprotein that is absent in cervicovaginal secretions between 24-36 weeks,
but becomes detectable again as term approaches. (1)
A
negative fFN is associated with 96% negative predictive value for preterm delivery in the next 7
days. (1) A positive test is less specific.
Performed
on speculum exam if cervix <3cm dilated and no blood or amniotic fluid is seen. The
sample should be collected from the posterior fornix of the vagina using the fetal fibronectin kit.
Question 10 : FT
Question Information:
A 26-year-old woman presents to her General Practitioner with her 4-year-old son. He has had a bright
red rash over both his cheeks. This appeared yesterday following a three day history of sore throat and
fever that have now resolved. She is concerned as she is 18 weeks pregnant. She is asymptomatic.
Her physical examination is unremarkable.
Question:
What is the next most appropriate step in management? (1 mark) Justify your answer. (1 mark)
Choice 1: null Score : 0
Choice Feedback:
Answer
Offer serological testing for parvovirus-specific IgG
Justification
Serological
testing for parvovirus-specific IgG to determine susceptibility should be offered to her,
although her overall risk of fetal damage is extremely low considering she is 35 weeks pregnant. Even if
positive, no intervention is available to prevent fetal infection or damage. Neither termination of
pregnancy nor amniocentesis is recommended for diagnosis of asymptomatic intrauterine fetal
infection.
Maternal
infection in the first half of pregnancy is associated with 10% excess fetal loss and hydrops
fetalis in 3% of cases, of which up to 60% resolve spontaneously or with appropriate management. No
congenital abnormalities or long-term sequelae have been attributed to parvovirus B19 infection.
Asymptomatic
fetal infection occurs in up to 50% of cases following proven maternal infection in
pregnancy. The small risk of fetal damage is virtually confined to the first half of pregnancy.
References
http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2000-cdi2403s-
cdi24msa.htm
Synopsis
Recommended learning outcomes from this set of Obstetrics and Gynaecology SAQs include:
1.Ovarian mass work-up
2.Menorrhagia - causes, including endometrial hyperplasia
3.Mastitis
4.Hyperemesis gravidarum
5.Miscarriage
6.Pap smear screening guidelines
7.Contraception in specific medical conditions
8.Bacterial vaginosis
9.Preterm labour
10.Parvovirus infection in pregnancy