clinicopathological conference ob-gyn deepak

DISCUSSANTS:

• Ghimire, Deepak• Romero, Jiesta Anna Monica• Campugan, Harjarra Kate• Abraham, Leonard

SOUTHWESTERN UNIVERSITYSchool of Medicine

Department of Obstetrics & Gynecology

CLINICO-PATHOLOGICAL CONFERENCE

MARCH 16,2016

General Data

•A case of R.V.•28 years old female

•G2P1011

•LMP : October 30, 2013 •Admitted on December 25,2013

Chief Complaints

•Epigastric pain

History of Present Illness

•Onset of localized epigastric pain

•No other associated signs and symptoms

10 days PTA


•Persistence of epigastric pain •Radiating at the Right Lower Quadrant area—Sought consultation with a Gastroenterologist

–Prescribed Omeprazole 20 mg capsule BID

–Temporary relief of pain

7 days PTA


•Condition persisted •Prompted admission at SHH- Department of Medicine

•Referred to the SHH-Department of Surgery

One day PTA


•Referred to the Department of OB & GYN–Persistent epigastric pain–Radiating to the entire abdomen–Associated with muscular-like pain over the right shoulders

Few hours after admission

Obstetrical History

No of Pregnancy

Year Outcome(AOG)

Mode of delivery

Hospital delivered

Indication Remarks

G1 2011 Full Term , male

Cesarean Section

VSMMC Breech -

G2 2013 Spontaneous abortion

- - - NO Dilatation & curettage done

Menstrual History

•12 years old x 28- 30 days cycle x 5 days

•Consumes 3 pads per day, moderately soaked.

•No dysmenorrhea.

Sexual History

•Coitarche at 19 years old •4 sexual partners•Denies history of sexually transmitted disease

Contraception History

•Combined oral contraceptive pills–2 years ago– Duration 7 months

Past Medical History

•Known asthmatic since childhood –Last attack was unrecalled

•No food & drug allergy

•Previous Hospitalization –VSMMC , 2011–Cesarean delivery of term pregnancy in breech presentation

Personal Social History

•Non-smoker•Non-alcoholic beverage drinker. •Worked as a masseuse in a local spa and massage unit.

Family History

•Unremarkable

Physical Exam

•Patient is awake, conscious ,coherent and afebrile

•Vital signs: •BP: 90/60 mmHg•HR: 86bpm•RR:1 6cpm•Temp: 36.7'C

Physical Exam

•Skin: Warm, Good turgor, (+) Pallor

•HEENT: Pale palpebral conjunctivae, Anicteric sclerae

•Chest & Lungs: ?

•Cardiovascular : ?

Physical Exam

•Abdomen: –Flat , soft , Normoactive bowel sounds

–direct & rebound tenderness (Epigastric & Right Lower abdomen )

Speculum exam

•Cervix congested•Non-foul smelling non-bloody discharges

Bimanual Pelvic Exam

•Cervix : Closed, firm, posterior with

equivocal tenderness on palpation

•Uterus: Slightly tender, not

enlarged,

•Adnexa: (+) tenderness at the right

adnexa

•Discharges: Non-foul smelling,

scanty blood-tinged discharges.

Rectal Exam

•Good sphincteric tone•Tender towards the right area• No palpable mass •(+) fecal material on examining finger

Laboratory Results

CBC results

Value Ref.

WBC 20.7 x 103/mm3 4.4 -11.0

HGB 8.4 g/dl 12.3-15.3

HCT 26.6% 35.9-44.6

PLT 252 x 103/mm3 150-450

Laboratory Results

Blood test results

Value Ref.

SGPT 7 Up to 41 U/L

SGOT 13 Up to 33 U/L

Alkaline Phosphatase 62.0 Up to 32 U/L

Serum Amylase 37.0, 0-85 U/L

Serum Lipase 13.0 13-60 U/L

Serum Na 137.0 136 – 145 mmol/L

Serum K 3.6 3.5 – 5.1 mmol/L

LDH 146.0 132-228 U/L

Ultrasound of the Abdomen

•Normal-sized liver with diffuse fatty changes •Normal Gallbladder, Pancreas, Spleen ,both kidneys & Urinary Bladder

•Normal-sized anteverted uterus •Adnexa not visualized (obscured by intraperitoneal fluid)

• (+) complex mass at right lower abdomen

Issues ?

What is her usual Blood pressure? Any new medication given by SHH-IM ? What are chest and Cardiovascular findings?

Is there urine Pregnancy test done ?Is transvaginal ultrasound (TVS) done ?

What is the description of epigastric pain ?

Salient features of the case

•28 Years old multigravid •8 weeks amenorrhea • 10 days history of persistent epigastric pain radiating to entire abdomen•(+) muscular like pain right shoulder •History of operative delivery & spontaneous abortion •Multiple sexual partners•History of combined oral contraceptive use


•Afebrile with blood pressure in lower margin (90/60 mmhg)•Pallor & pale palpebral conjuctivae •Direct and rebound tenderness on epigastric and right lower abdomen •Right adenxal tenderness • Tenderness in rectal exam


•Leukocytosis of 20,000 /mm3

•Moderate Anemia (Hgb 8.4 g/dl) •UTZ finding :

–(+) free intraperitoneal fluid (∞ hemoperitoneum)–(+) complex mass at RLQ

Differential Diagnoses

Salient features

Ruptured Corpus luteum cyst

Ectopic pregnancy

Ovarian tumor

Acute Appendicitis

Appendicitis

•Classically Epigastric pain is followed by Nausea, vomiting & anorexia

•Epigastric Pain then shifts to RLQ • (+) Signs of peritoneal irritation like Direct & rebound tenderness

•May have fever, mild leukocytosis and (+) periappendiceal fluid

•WBC >18,000 cells/mm3 raise the possibility of a ruptured appendix

Appendicitis

RULE IN RULE OUT REMARKS

HISTORY & PHYSICAL EXAM

•Common in 10-30 y.o•(+) epigastric pain •(+) RLQ pain & tenderness•May have Adnexal tenderness•May have Rectal pain

• (-) Nausea (-) anorexia•Peritoneal fluid not explained•Amenorrhea not explained•Shoulder pain less defined

LABORATORY •WBC elevated >10,000/mm3

• Appendiceal abscess may present as complex mass• (+) periappendiceal fluid

• anemia is not explained


Salient features


Ectopic pregnancy

Ovarian tumor

Acute Appendicitis

Ovarian Tumor

• Second most common gynecologic cancer.

• 80% are benign in reproductive age group

• May arise from – Epithelium ( 70%)– Stroma (15%)– Germ cells (10%)– Metastatic (5%)

• Associated with low parity and infertility

1. Serous cystadenomas

•.Most frequent ovarian epithelial tumor•.Benign: reproductive age group •.May contain serous fluid and solid- tissue component•.Ascites, abdominal discomfort•.Diagnosis established by histologic exam•.elevated serum CA-125 (>90%)

Ovarian Tumor

• Ovarian tumors are common

• 80% are benign in reproductive age group

• May arise from – Epithelium ( 70%)– Stroma (15%)– Germ cells (10%)– Metastatic (5%)

• Associated with low parity and infertility

1. Mature cystic teratoma

•most common neoplasm of the ovary in reproductive years•contains derivatives of 3 germ layers (ectoderm, mesoderm & endoderm)•Mostly unilateral (15% bilateral ) •Dull aching pain in lower abdomen, heaviness •Complication

• Torsion (15–20%)• rupture(1%)

•CA-19-9 can be used as aid in the diagnosis

Ovarian tumor



•common in reproductive age group•May produce dull aching pain• (+) adnexal tenderness •(+)•(+) pallor / (+) anemia

•(-)Family History•(+) multigravid (+) COCP•(-) palpable mass • epigastric pain not well explained•Amenorrhea uncommon •Shoulder pain not explained

LABORATORY (+) complex mass(+) free intraperitoneal fluid

•Leukocytosis uncommon


Salient features


Ectopic pregnancy

Ovarian tumor

Acute Appendicitis


•Functional cyst developing in the luteal phase of the ovarian cycle

•Regresses spontaneously in Corpus albicans when pregnancy does not occur

•Failure to regress Progesterone and estrogen secretion•Amenorrhea followed by uterine bleeding• Prone to hemorrhage and torsion •Rupture unilateral abdominal pain & features of peritoneal hemorrhage




•Reproductive age (18-35)•Occurs after ovulation•(+) amenorrhea •Described cause of RLQ pain (epigastric pain )•Ruptured ( pallor, hemodynamic changes)•(+) direct & rebound tenderness• adnexal tenderness

•No history of recent exercise and sexual intercourse• (-) sharp pain at the lower abdomen•Amenorrhea not followed by vaginal bleeding

LABORATORY •Leukocytosis•Hematocrit may fall •complex adnexal mass in UTZ

•Normal sized uterus(indicates no Intrauterine pregnancy)

•βhCG-levels not given ?

•Cannot totally rule out •but less likely explains amenorrhea without vaginal bleeding


Salient features


Ectopic pregnancy

Ovarian tumor

Acute Appendicitis

Ectopic pregnancy

•Defined as implantation outside normal uterine cavity

•suspected in any women with amenorrhea and any abdominal pain

•Triad : Amenorrhea, abdominal pain, irregular vaginal bleeding (<50 %)

•Usually have risk factors prior pelvic surgery, multiple sexual partners, IUD devices use.

Ectopic pregnancy

•Fate of ectopic pregnancy depends on site of implantation

•Presents with abdominal pain (>98%) •shoulder pain & epigastric pain are rare feature (atypical)

•Signs of peritoneal irritation & cervical/adnexal tenderness

•Hemodynamic instability

Ectopic pregnancy



•Reproductive age,•Amenorrhea, abdominal pain •(+)Risk factors- multiple sexual partner, prior pelvic surgery, Prior abortion• (+) peritoneal signs/shoulder pain •(+) right adenxal tenderness •(+)pallor, low range B.P.

•Epigastric pain is not typical feature

LABORATORY •Leukocytosis•Low Hematocrit•UTZ

• free intraperitoneal fluid •(+) complex mass at RLQ

•Cannot RULE OUT


Salient features

Ruptured corpusluteum cyst

Ectopic pregnancy

Ovarian tumor Acute Appendicitis

MOST LIKELY DIAGNOSIS

Ruptured Ectopic pregnancy

Ectopic pregnancy

DISCUSSION

Incidence

• The frequency of ectopic pregnancy is 1 .3-2 %

• Majority of patients with ectopic pregnancy are 2 1-30 years age group

• Multiparous women were found to be more prone to have ectopic pregnancy

• The gestational age ranged between 4-11 weeks and the most frequent gestational age was around 6 weeks.

Risk factors for ectopic pregnancy

High risk Moderate risk Slight risk

Tubal surgery Infertility Previous pelvic/abdominal surgery

Sterilization Previous genital infections

Cigarette smoking

Previous ectopic pregnancy

Multiple sexual partners

Vaginal douching

In utero exposure to diethylstilbestrol

Early age at first intercourse (< 18 years)

Use of IUD Previous spontaneous abortion or induced abortion

Documented tubal pathology

Mechanism of ectopic pregnancy

Features of Ectopic pregnancy

•Acute abdominal pain (100%) •Amenorrhea (6-10 weeks)•Slight or No vaginal bleeding•Syncope, hypotension & pallor•Pelvic tenderness, Uterus enlarged & soft

•Fever is unusual

Ultrasound findings indicative of ectopic pregnancy

1. Empty uterus with a tubal ring 2. Complex adnexal mass - most

common finding 3. Moderate-to-large amount of free

fluid (70%) 4. Definite extrauterine pregnancy

(20%) Frates MC, Brown DL, Doubilet PM, Hornstein MD. Tubal rupture in patients with ectopic pregnancy:

diagnosis with transvaginal US. Radiology. Jun 1994;191(3):769-72. [View Abstract]

http://www.medscape.com/medline/abstract/8184061?src=mckb









Other finding in suspected ectopic pregnancy

• shoulder tip pain, syncope and shock - 20%

• Abdominal tenderness- > 75%. • Cervical motion tenderness - 67% • palpable adnexal mass - 50%.

Weckstein LN, Boucher AR, Tucker H, et al. Accurate diagnosis of early ectopic pregnancy. Obstet Gynecol1985;65:393–397.

• one third of women with ectopic pregnancy have no clinical signs

• 9% have no symptoms

Predictor of ruptured ectopic pregnancy

•Severe Abdominal pain With Rebound tenderness

•Fluid in Pouch of Douglas In TVS•Low serum hemoglobin (pallor)

Doppler ultrasound can differentiate ectopic pregnnancy from other adnexal mass

Ectopic pregnancy : common implantation sites

Localizing ectopic pregnancy : common sites

Site % incidence Fate

Tubal(95-95 % )

Ampullary (70%)

Wide, distensible Ruptures at 8-12 weeks (tubal abortion)

Isthmus (12%)

Narrowest part of tube Ruptures Early 6-8 weeks, bleeds profusely

Fimbrial end (11%)

Part close to ovary Rupture is rare, mainly aborts

Cornual (2-3%)

More distensible Detected late (14 weeks) , devastating hemorrhage

Ovarian 3 % more distensible May rupture early ,

Abdominal 1-2 % Depends on site Adnexal May go up to term Omental may rupture < 5 weeks

Other <1 % depends painless vaginal bleeding (cervical)

Spiegelberg criteria for diagnosis of ovarian pregnancy

1 The gestational sac is located in the region of the ovary.

2 The ectopic pregnancy is attached to the uterus by the ovarian ligament.

3 Ovarian tissue in the wall of the gestational sac is proved histologically.

4 The tube on the involved side is intact.

Abdominal pregnancy

• The implantation sites may be • Omentum (least common) • Liver, ovaries, pouch of doughlas or • Broad ligament (most common)

•Primary abdominal pregnancy• Secondary Abdominal pregnancy after tubal rupture or tubal abortion

Studdiford's criteria for primary abdominal pregnancy

1 Normal bilateral tubes and ovaries with no evidence of recent or past pregnancy.

2 No evidence of a uteroperitoneal fistula.

3 The presence of pregnancy related exclusively to the peritoneal surface, early enough to eliminate the possibility of secondary implantation after primary tubal nidation

Features favoring abdominal pregnancy

•Predominantly epigastric pain without lower abdominal pain

•Signs of massive peritoneal bleeding in early gestation

•No vaginal bleeding•Normal sized uterus •Equivocal cervical tenderness

FINAL DIAGNOSIS

Ruptured Ectopic pregnancy(most likely Omental)

clinicopathological conference ob-gyn deepak

Documents