OB case presentation

Shih, Chun I S.

San Beda College of Medicine

Identifying data

• 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 5 y/o)

1986 Female Home NSD None

G6 1989 Male Home NSD None

Gyne history

• 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

• 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

• (-) weight loss• (-) fever• (-) difficulty of breathing• (-) cough• (-) chest pain• (-) palpitation• (-) edema• (-) easy fatigability

PE upon admissionVital 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 May 9, 2011 May 18, 2011CBC Blood chemistry CBCHgb: 96 mg/dlHct: 0.34WBC: 7.7 * 109/LPlt: 385, 000

Na: 129K: 3.3Cl: 100BUN: 1.98Crea: 67PT: 103aPTT: 43.8

Hgb: 129 mg/dlHct: 0.44WBC: 6.6* 109/LPlt: adequate

Medications:

• Ampicillin 2g through IV

• Cefalexin 500mg/cap, 1 cap TID

• Mefenamic acid 500 mg, 1 cap q6h

Course in the wardsDay in hospital

MDs orders

Diet Meds taken

IV fluids Labs done

Vital signs & PE findings

May 18 day 1- 6am

For fractional D& C

NPO Ampicillin 2 gm TIV (-) ANST

IVF D5LRS 1L * 8h

Request for CBC

VS q1- stable

Day 1 11amS/P F D&C

To RR DAT Cefalexin 500mg/cap 1 cap TIDMefenamic acid 500 mg 1 cap q6h

IVF to continue

Monitor VS q15min for 1hr then q1

Day 1- 2pm

To room LPerineal hygiene advised

DAT Cont med IVF to continue

Normal CBC results

VS- stable q4Min bleedNo pallor

May 19 day 2

MGHFf up at OPD on May 27 with histopath result

DAT Cont med Ff up histopath after 1 week

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 40 y/o above

Symptoms: 35% with pelvic pain, usually presents as secondary dysmenorrhea or dyspareunia or both

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 ad

enomyosis. 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 !