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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