Download OB case presentation

OB case presentation
Shih, Chun I S.
San Beda College of Medicine
Identifying data
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E.A.
53 y/o
G6P5 (6005)
Married
RC
Marikina
Chief complaint
• Heavy menstrual bleeding
History of present illness
• 1 year PTC, heavy and prolonged menses lasted for 15
days, 4 drapers per day, no vaginal discharge and bowel
or bladder symptoms noted. Consult at Amang
Rodriguez and was diagnosed with myoma, she was
advised to undergo an operation but she lost to follow up.
• 2months PTC, still had heavy prolonged menses, with
hypogastric pain described as crampy in character, no
precipitating factors, radiating to hips, 8/10 intensity and
the pain lasted for entire day during the days of
menstrual period, no medications were taken and the
patient also didn’t seek any consult.
• 2 weeks PTC, there was increased vaginal bleeding for
6days, patient consulted at QMMC OB-ER and was
prescribed with Tranexamic acid & Ferrous sulfate, she
was also advised admission but she refused. Hence she
was rather advised to undergo a transvaginal ultrasound.
• 1 week PTC, patient finally decided to go back to QMMC
with her ultrasound result, she consulted at OB OPD and
in ultrasound it showed that she has posterior uterine
wall adenomyosis and she was scheduled for fractional
curettage on May 18, hence the admission.
OB history
Year
Gender
Place
Type of
delivery
Fetomaternal
complication
G1
1997
Male
Home
NSD
None
G2
1980
Male
Home
NSD
None
G3
1982
Male
Home
NSD
None
G4
1984
Female
Home
NSD
None
G5 (died on
1986
Female
Home
NSD
None
1989
Male
Home
NSD
None
5 y/o)
G6
Gyne history
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LMP: April 20, 2011 for 6 days
PMP: March 2011 for 15 days
Menarche: 13 y/o
Interval: Regular
Duration: 6days
Amount: 5pads/day
Symptom: No dysmenorrhea
Sexual hx
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Coitarche: age of 18
One partner (her husband)
Ave. sexual intercourse of 3x/ week.
Husband had 67 other sexual partners
(-) intermenstrual bleeding, dyspareunia,
postcoital bleeding and any form of STDs.
Contraceptive hx
• Oral contraceptive pill use for 13 years,
from year 1989-2002.
Past medical hx
• No past history of hypertension, diabetes
mellitus, heart disease, thyroid problem,
lung disease, kidney disease or
cerebrovascular disease.
Family medical hx
• Motherside has both hypertension and
diabetes mellitus.
Personal social hx
• Elementary school graduate
• Nonsmoker and an occasional alcoholic
beverage drinker (Redhorse, 1 bottle)
• No history of illicit drug use.
• Preferred foods are chicken, beef, fish and
vegetables.
Review of systems
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(-) weight loss
(-) fever
(-) difficulty of breathing
(-) cough
(-) chest pain
(-) palpitation
(-) edema
(-) easy fatigability
PE upon admission
Vital Signs:
• Blood pressure: 120/ 70 mmHg
• Temperature: 36.3 degree Celsius
• HR: 81 beats per minute
• RR: 20 cycles per minute
Skin: palms warm and dry, nails without clubbing and cyanosis.
Head, Eyes, Ears, Nose, Throat (HEENT)
• Head: Normocephalic, fine and equal hair distribution. No
bumps, lesions, scars or masses.
• Eyes: Pink conjunctivae; anicteric sclera, (+) pupillary light
reflex round regular and equally reactive to light, (+) ROR, (+)
corneal reflex. Extraocular movements intact.
• Ears: Right and left ear canal clear, TM with good cone of
light. Acuity good to whisphered voice.
• Nose: No nostril occlusion. Nasal mucosa pink, septum
midline. No sinus tenderness
• Mouth: Oral mucosa pink. Dentition good. Tongue
midline. Pharynx without tenderness and exudates.
• Neck: Trachea midline. Thyroid isthmus barely palpable,
lobes not felt. No cervical lymphadenopathy.
Thorax and lungs: Thorax symmetric and good excursion.
Chest wall resonant upon percussion. Breath sounds
vesicular with no added sounds.
Cardiovascular: Carotid upstrokes brisk without bruits. No
heaves and thrills. Apical pulse discrete and tapping
palpable on the 5th interspace anterior axillary line, PMI:
parasternal border 5th intercostals space. Good S1 and
S2; no S3 or S4. No murmurs.
Abdomen: Flabby and soft abdomen. Normoactive bowel
sounds. No tenderness upon light and deep palpation.
Spleen and kidneys not felt.
Pelvic: speculum exam showed that cervix is pink, smooth,
with no discharge, bleeding or erosions and internal
exam showed that the uterus is symmetrical, enlarged to
16 weeks size.
Extremities: Extremities warm and without edema, calves
supple, nontender.
Musculoskeletal: No joint deformities. Good range of
motion in hands, wrists, elbows, shoulders, spine, hips,
knees, ankles.
Diagnosis
• Admitting diagnosis: G6P6 (6005)
Adenomyosis
• Final diagnosis: G6P6 (6005)
Adenomyosis with Endometrial polyps
• Procedures: fractional curettage then
schedule for TAHBSO
Laboratories:
May 6 Transvaginal ultrasound final
impression:
• Slightly anteverted uterus with diffuse,
myometrial echoes in the thicker posterior
wall compared to anterior wall suggestive of
adenomyosis. The endometrium is thickened
and hyperechoic. Both ovaries are normal in
size and echotexture. No free fluid in the cul
de sac.
May 9, 2011
CBC
Hgb: 96 mg/dl
Hct: 0.34
WBC: 7.7 * 109/L
Plt: 385, 000
May 9, 2011
Blood chemistry
Na: 129
K: 3.3
Cl: 100
BUN: 1.98
Crea: 67
PT: 103
aPTT: 43.8
May 18, 2011
CBC
Hgb: 129 mg/dl
Hct: 0.44
WBC: 6.6* 109/L
Plt: adequate
Medications:
• Ampicillin 2g through IV
• Cefalexin 500mg/cap, 1 cap TID
• Mefenamic acid 500 mg, 1 cap q6h
Course in the wards
Day in
hospital
MDs
orders
Diet
Meds
taken
May 18
day 16am
For
fractional
D& C
NPO
Ampicillin IVF
2 gm TIV (-) D5LRS
ANST
1L * 8h
DAT
Cefalexin
IVF to
500mg/cap continu
1 cap TID
e
Mefenamic
acid 500
mg 1 cap
q6h
Day 1
To RR
11am
S/P F D&C
IV fluids Labs
done
Request
for CBC
Vital signs
& PE
findings
VS q1stable
Monitor
VS
q15min
for 1hr
then q1
Day 12pm
To room L
Perineal
hygiene
advised
DAT
Cont med
May 19
day 2
MGH
Ff up at
OPD on
May 27
with
histopath
result
DAT
Cont med
IVF to
continu
e
Normal
CBC
results
Ff up
histopath
after 1
week
VS- stable
 q4
Min bleed
No pallor
Histopath result:
Endometrial polyp
• Endometrial curettings: consists of several tan
brown soft, irregular tissues admixed with blood
clots aggregately measuring 1.5 by 1.5 by 0.3cm.
• Endocervical curettings: consists of several tan
brown soft, irregular tissues admixed with
mucoid materials aggregately measuring 0.5 by
0.5 by 0.3 cm.
Discussion: ADENOMYOSIS
• Adenomyosis has often been referred to
as endometriosis interna. (Misleading)
• The cause of adenomyosis is not known.
(Theory: compromised barrier)
Endometriosis
Adenomyosis
(+) Endometrial glands and
stroma identical to lining of
uterus in aberrant location
(+) Endometrial glands and
stroma deep in myometrium
Occurs primarily in 25-45 y/o
Symptoms: 35% with pelvic
pain, usually presents as
secondary dysmenorrhea or
dyspareunia or both
40 y/o above
Symptoms: Derived from
berrant glands of basalis layer
of endometrium (decidua
basalos no proliferative and
secretory change)  majority
asymptomatic
Signs: enlarged ovaries, tender
nodules within pelvis
Signs: enlarged uterus, rarely
more than 14w size
• 2 distinct presentations: diffused and focal/ adenomyoma
• It is often difficult to distinguish on physical examination
from uterine leiomyomas. However, the ultrasound
appearance of leiomyoma helps to distinguish the two.
• It is most unusual for the uterine enlargement associated
with adenomyosis to be greater than a 14-week-size
gestation unless the patient also has uterine myomas.
• Over 50% of women with adenomyosis
are asymptomatic or have minor
symptoms that do not annoy them enough
to seek medical care.
• Symptomatic adenomyosis usually
presents in women between the ages of
35 and 50.
• The classic symptoms of adenomyosis are
secondary dysmenorrhea and
menorrhagia.
• Occasionally the patient complains of
dyspareunia.
Medical:
• There is no satisfactory proven medical treatment for
adenomyosis. Occasionally, treated with GnRH agonists,
cyclic hormones, or prostaglandin synthetase inhibitors
for their abnormal bleeding and pain.
Surgical:
• Hysterectomy is the definitive treatment if this therapy is
appropriate for the woman's age, parity, and plans for
future reproduction.
• Deep tissue laser technique: For women who still wish
to conceive
Endometrial Polyps
• Endometrial polyps are localized
overgrowths of endometrial glands and
stroma that project beyond the surface of
the endometrium.
• They are soft, pliable and may be single or
multiple. Most polyps arise from the
fundus of the uterus.
• The cause of endometrial polyps is unknown.
Because polyps are often associated with
endometrial hyperplasia, unopposed estrogen
may be one cause.
• The majority of endometrial polyps are
asymptomatic.
• Those that are symptomatic are associated with
a wide range of abnormal bleeding patterns. No
single abnormal bleeding pattern is diagnostic
for polyps.
• Histologically, an endometrial polyp has three
components: endometrial glands, endometrial
stroma, and central vascular channels.
• Malignant transformation in an endometrial
polyp has been estimated to be as high as 0.5%.
Malignant change, when found in an endometrial
polyp, is usually curable, and the endometrial
carcinoma is most often of a low stage and
grade.
• The optimal management of endometrial
polyps is removal by hysteroscopy with
D&C.
• Because of the frequent association
of endometrial polyps and other
endometrial pathology, it is important to
examine histologically both the polyp and
the associated endometrial lining.
谢谢!