Clinicopathological Conference OB-GYN Deepak

SOUTHWESTERN UNIVERSITY
School of Medicine
Department of Obstetrics & Gynecology
CLINICO-PATHOLOGICAL CONFERENCE
DISCUSSANTS:
Ghimire, Deepak
Romero, Jiesta Anna Monica
Campugan, Harjarra Kate
Abraham, Leonard
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

10 days PTA
Onset of localized epigastric

pain
No other associated signs and
symptoms

7 days PTA
Persistence of epigastric pain

Radiating at the Right Lower
Quadrant area
Sought consultation with a
Gastroenterologist
Prescribed Omeprazole 20 mg capsule

One day PTA
Condition persisted
Prompted admission at SHHDepartment of Medicine
Referred to the SHHDepartment of Surgery

Few hours after admission
Referred to the Department of

OB & GYN
Persistent epigastric pain
Radiating to the entire abdomen
Associated with muscular-like
pain over the right shoulders
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
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
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?
What is the description of
epigastric pain ?
Is there urine Pregnancy test
done ?
Is transvaginal ultrasound (TVS)
done ?
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
Ectopic
pregnancy
Ruptured Corpus
luteum cyst
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
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
ascomplex mass
(+) periappendiceal fluid
anemia is not explained
REMAR
KS
Salient features
Ectopic
pregnancy
Ruptured Corpus
luteum cyst
Ovarian
tumor
Acute
Appendicitis
Ovarian Tumor
1. Serous cystadenomas
Second most commongynecologiccancer.

80% are benign in reproductive
May arise from
Epithelium ( 70%)
Stroma (15%)
Germ cells (10%)
Metastatic (5%)
.Most frequent ovarian epithelial

tumor
age
group
.Benign: reproductive age group
.May contain serous fluid and solidtissue component
.Ascites, abdominal discomfort
.Diagnosis established by histologic
exam
.elevated serum CA-125(>90%)
Associated with low parity and infertility
Ovarian Tumor
Ovarian tumors are common
1. Mature cystic teratoma
most common neoplasm of the ovary

in reproductive
80% are benign in reproductive age
group years
contains derivatives of 3 germ layers
May arise from
(ectoderm, mesoderm & endoderm)
Mostly unilateral (15% bilateral )
Epithelium ( 70%)
Dull aching pain in lower abdomen,
heaviness
Stroma (15%)
Complication
Germ cells (10%)
Torsion (1520%)
rupture(1%)
Metastatic (5%)
CA-19-9can be used as aid in the
diagnosis
Associated with low parity and infertility
Ovarian tumor
RULE IN
RULE OUT
HISTORY &
PHYSICAL
EXAM
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
REMARKS
Salient features
Ectopic
pregnancy
Ruptured Corpus
luteum cyst
Ovarian
tumor
Acute
Appendicitis
Ruptured Corpus luteum cyst

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
Ruptured Corpus luteum cyst

RULE IN
RULE OUT
REMARKS
HISTORY &
PHYSICAL
EXAM
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
Cannot totally
rule out
but less likely
explains
amenorrhea
without
vaginal
bleeding
LABORATORY
Leukocytosis
Hematocrit may fall
complex adnexal mass in UTZ
Normal sized uterus

(indicates no Intrauterine pregnancy)
hCG-levels not given ?
Salient features
Ectopic
pregnancy
Ruptured Corpus
luteum cyst
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
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
RULE IN
RULE OUT
HISTORY &
PHYSICAL
EXAM
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
REMARKS
Cannot
RULE OUT
Salient features
Ectopic
pregnancy
Ruptured corpus
luteum cyst
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
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
Documentedtubal
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]
Other finding in suspected

ectopic pregnancy
shoulder tip pain, syncope and shock 20%
one third of women with ectopic pregnancy
have no clinical signs
Abdominal tenderness- >9%75%.
have no symptoms
Cervical motion tenderness - 67%
palpable adnexal mass - 50%.
Weckstein LN, Boucher AR, Tucker H,et al.Accurate diagnosis of early ectopic pregnancy.
Obstet Gynecol1985;65:393397.
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
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
more distensible
May rupture early ,
Abdominal 1-2 %
Depends on site
Adnexal May go up to term

Omental may rupture < 5 weeks
Other
depends
Tubal
(95-95 % )
Ovarian
3%
<1 %
painless vaginal bleeding (cervical)
Spiegelberg criteria for diagnosis of ovarian pregnancy
Thegestational sacis located in the region of theovary.
The ectopic pregnancy is attached to the uterus by the

ovarianligament.
Ovarian tissuein the wall of the gestational sac is proved histologically.
Thetubeon 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.
No evidence of a uteroperitoneal fistula.
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)

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What were the chief complaints of the patient?

What were the chief complaints of the patient?

What were the findings from the physical examination?

What were the findings from the physical examination?

SOUTHWESTERN UNIVERSITY

History of Present Illness

Onset of localized epigastric

History of Present Illness

Persistence of epigastric pain

History of Present Illness

History of Present Illness

Referred to the Department of

Past Medical History

No food & drug allergy

Personal Social History

HEENT: Pale palpebral conjunctivae, Anicteric

Bimanual Pelvic Exam

136 145 mmol/L

3.5 5.1 mmol/L

Ultrasound of the Abdomen

Salient features of the case

Salient features of the case

Afebrile with blood pressure in lower

Salient features of the case

Leukocytosis of 20,000 /mm3

(+) free intraperitoneal fluid (

Common in 10-30 y.o

(-) Nausea (-) anorexia

WBC elevated >10,000/mm3

anemia is not explained

Second most commongynecologiccancer.

.Most frequent ovarian epithelial

Associated with low parity and infertility

1. Mature cystic teratoma

most common neoplasm of the ovary

common in reproductive age group

(+) complex mass

Ruptured Corpus luteum cyst

Ruptured Corpus luteum cyst

Reproductive age (18-35)

Normal sized uterus

hCG-levels not given ?

irregular vaginal bleeding

Usually have risk factors prior pelvic

MOST LIKELY DIAGNOSIS

Ruptured Ectopic pregnancy

Risk factors for ectopic pregnancy

Early age at first

Features of Ectopic pregnancy

Ultrasound findings indicative of ectopic pregnancy

1. Empty uterus with a tubal ring

Other finding in suspected

Predictor of ruptured ectopic

Ectopic pregnancy : common

Localizing ectopic pregnancy :

Ruptures at 8-12 weeks (tubal abortion)

Narrowest part of tube

Ruptures Early 6-8 weeks, bleeds profusely

Part close to ovary

Rupture is rare, mainly aborts