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Gynaecology osce
Myometrial hypertrophy
the term “myometrial hypertrophy” has been used to designate
symmetrically enlarged uteri weighing 120 grams or more in which no
pathologic changes other than increased size can be demonstrated.
Evidence is presented that the increase in weight of the uterus is due to
hypertrophy of the smooth muscle fibers of the myometrium.
Endometriosis is a condition in which tissue similar to that which lines

the inside of your uterine wall grows outside of your uterus.
Obstetric anaesthesia and analgesia

anesthesia is the care provided for surgical intervention (e.g., cesarean
section), and analgesia is the care provided for pain management (e.g.,
labor epidural, post-cesarean pain control)
Abortion types
There are two kinds of abortion — the abortion pill and in-clinic
abortion. Medication abortion (also known as the abortion pill) consists
of using two different medicines called mifepristone and misoprostol to
end a pregnancy.
Benign ovarian cyst

Cysts can be non-cancerous (benign) or cancerous, and should
always be removed if suspected to be cancerous. However, even when
a cyst is benign, doctors often recommend removal due to concerns
about serious complications, such as the cyst bursting or causing the
ovaries to twist. usually treated with surgery, such as laparoscopy to
remove the tumor. ibuprofen for pain antibiotics for pelvic inflammation,
& ethinyl estradiol
Face presentation
A face presentation occurs when the face is the presenting part of the
baby. In this position, the baby's neck is deflexed (extended backward)
so that the back of the head touches the baby's back. This prevents
head engagement and descent of the baby through the birth canal.
Chlamydia vs Gonorrhoea
For chlamydia, women may have vaginal discharge that has a strong
odor or is yellowish, and men may have cloudy or clear discharge
around the tip of the penis. For Gonorrhea, women may have discharge
from the vagina that is green, yellow, or white. Chlamydia is caused by
an overgrowth of the bacteria Chlamydia trachomatis, while gonorrhea
is caused by the bacterium Neisseria gonorrhoeae. In terms of
symptoms, both chlamydia and gonorrhea may result in a burning
sensation during urination and an abnormal discharge from the genitals.
Amenorrhea
Amenorrhea is the absence of menstruation or missing one or more
menstrual periods.
Primary amenorrhea refers to the absence of menstruation in someone
who has not had a period by age 15. The most common causes of
primary amenorrhea relate to hormone levels, although anatomical
problems also can cause amenorrhea.
Gonadal agenesis
gonadal agenesis is characterized by a rudimentary streak gonad. It is
composed of a dense, hyalinized fibrous tissue in which the germ cells
or the germ structures are entirely missing.
Polycystic ovary syndrome (PCOS) is a condition in which the ovaries
produce an abnormal amount of androgens, male sex hormones that are
usually present in women in small amounts. The name polycystic ovary
syndrome describes the numerous small cysts (fluid-filled sacs) that
form in the ovaries.
Stages of Parturition
Are 3
Dilation
The first stage of parturition starts with the onset of labor. It continues
until the cervix is fully dilated. This dilation is divided into two phases:
● Latent phase. The cervix is 0 to 4 centimeters (cm) dilated.
● Active phase. The cervix is 4 to 10 cm dilated.
Expulsion
The second stage of parturition starts at full dilation and continues until
birth. This stage also has two phases:
● Passive phase. The baby’s head moves down through the vagina.
● Active phase. The mother feels a need to push, or contract the
abdominal muscles in time with uterine contractions.

Placental
The third stage of parturition starts after birth and ends with the
delivery of the afterbirth (placenta and membranes).
Miscarriage treatment
1. Dilation and curettage (also called D&C). This is a procedure to
remove any remaining tissue from the uterus. .
2. Medicine. Misoprostol that can help your body pass tissue that's
still in the uterus.
Hypogonadism
Hypogonadism occurs when your sex glands produce little or no sex
hormones. The sex glands, also called gonads, are primarily the testes
in men and the ovaries in women. Sex hormones help control secondary
sex characteristics, such as breast development in women, testicular
development in men, and pubic hair growth.
Hydrops fetalis
Hydrops fetalis is a serious condition. It occurs when abnormal amounts
of fluid build up in two or more body areas of a fetus or newborn.
There are two types of hydrops fetalis, immune and nonimmune.
Amniotic fluid embolism

Amniotic fluid embolism is a life-threatening, acute and unexpected
birth complication that can affect both mother and baby. AFE is
characterized by acute and rapid collapse of mother and/or baby as a
result of an allergic-like reaction to amniotic fluid entering the maternal
circulatory system.
Menopausal transition
The menopausal transition (perimenopause) is the period that links a
woman's reproductive (childbearing) years and menopause. A woman
is said to be in menopause if she has had no menstrual periods for 1
year.
Iugr
Intrauterine growth restriction, or IUGR, is when a baby in the womb (a
fetus) does not grow as expected. The baby is not as big as would be
expected for the stage of the mother's pregnancy. This timing is known
as an unborn baby's "gestational age."
Lichen sclerosis
is a long-term skin condition that mostly affects the genital and anal
areas. It causes your affected skin to become thin, white, and wrinkly. It
is due to inflammation and other skin changes in the affected area.
Common symptoms include itching, irritation, and pain during sex.
Uterine rupture
is spontaneous tearing of the uterus that may result in the fetus being
expelled into the peritoneal cavity. Uterine rupture is rare. It can occur
during late pregnancy or active labor. Uterine rupture occurs most
often along healed scar lines in women who have had prior cesarean
deliveries.
Müllerian agenesis
also referred to as müllerian aplasia, Mayer–Rokitansky–Küster–Hauser
syndrome, or vaginal agenesis, has an incidence of 1 per 4,500–5,000
females Müllerian agenesis is caused by embryologic
underdevelopment of the müllerian duct, with resultant agenesis or
atresia of the vagina, uterus, or both.
Placental abnormalities
1.)Placenta previa occurs when the placenta covers some or all of the
cervix. If you have placenta previa early in pregnancy, it usually isn't a
problem. However, it can cause serious bleeding and other
complications later in pregnancy.
Symptoms: Placenta previa might cause bleeding throughout pregnancy
and during delivery.
2.)Placenta accreta occurs when the placenta attaches too deep in the
uterine wall but it does not penetrate the uterine muscle.
Symptoms:
Placenta accreta often causes no signs or symptoms during pregnancy,
although vaginal bleeding during the third trimester might occur.
3.) Placenta increta occurs when the placenta grows at least halfway
through the wall of the uterus and attaches itself to the uterine muscle.
4.)Placenta percreta occurs when the placenta grows completely

through the wall of the uterus; in some cases, placental tissue will
continue to grow into nearby pelvic organs, including the bladder or
colon.
Symptoms for Increta and Percreta:

Placenta increta and percreta often cause no signs or symptoms during
pregnancy, although vaginal bleeding during the third trimester might
occur.
Amniotic fluid embolism treatment

Amniotic fluid embolism requires rapid treatment to address low blood
oxygen and low blood pressure. Emergency treatments might include:
Catheter placement. A thin, hollow tube placed into one of your arteries
(arterial catheter) might be used to monitor your blood pressure.
There are 3 types of regional anesthesia: spinal, epidural and combined

spinal/epidural. With each type, medicines are placed near the nerves in
your lower back to “block” pain in a wide region of your body while you
stay awake. It can also be used if a cesarean birth becomes necessary.
A breech presentation is when the fetus presents buttocks or feet first

(rather than head first – a cephalic presentation). It has significant
implications in terms of delivery – especially if it occurs at term (>37
weeks).
There are three main breech positions:
● Frank breech. The buttocks are in place to come out first during
delivery. The legs are straight up in front of the body, with the feet
near the head. This is the most common type of breech position.
● Complete breech. The buttocks are down near the birth canal. The
knees are bent, and the feet are near the buttocks.
● Footling breech. One leg or both legs are stretched out below the
buttocks. The leg or legs are in place to come out first during
delivery.
Infertility
is a disease of the male or female reproductive system defined by the
failure to achieve a pregnancy after 12 months or more of regular
unprotected sexual intercourse.
First trimester screening is a prenatal test that offers early information

about a baby's risk of certain chromosomal conditions, specifically,
Down syndrome (trisomy 21) and extra sequences of chromosome 18
(trisomy 18).
Second trimester prenatal screening
Screening is usually done by taking a sample of the mother's blood

between the 15th and 20th weeks of pregnancy (16th to 18th is ideal).
The multiple markers include:
Alpha-fetoprotein screening (AFP).
● Abnormal levels of AFP may signal:
○ Open neural tube defects such as spina bifida
○ Down syndrome
○ Other chromosomal abnormalities
○ Defects in the abdominal wall of the fetus

○ Twins. More than one fetus is making the protein
○ A miscalculated due date, as the levels vary throughout
pregnancy
● hCG. Human chorionic gonadotropin hormone (a hormone made by
the placenta).
● Estriol. A hormone made by the placenta.
● Inhibin. A hormone made by the placenta.
A fetal ultrasound (sonogram) is an imaging technique that uses sound

waves to produce images of a fetus in the uterus. Fetal ultrasound
images can help your health care provider evaluate your baby's growth
and development and monitor your pregnancy.
Müllerian agenesis is caused by embryologic underdevelopment of the

müllerian duct, with resultant agenesis or atresia of the vagina, uterus,
or both. Patients with müllerian agenesis usually are identified when
they are evaluated for primary amenorrhea with otherwise typical
growth and pubertal development
When only reproductive organs are affected, the condition is classified
as MRKH syndrome type 1. Some women with MRKH syndrome also
have abnormalities in other parts of the body; in these cases, the
condition is classified as MRKH syndrome type 2. In this form of the
condition, the kidneys
may be abnormally formed or positioned, or one kidney may fail to
develop (unilateral renal agenesis).
Mullerian anomalies
Ovarian hyperstimulation
Ovarian hyperstimulation syndrome (OHSS) occurs when a woman's
ovaries swell and leak fluid into the body. This condition is a
complication that can occur in women who receive fertility treatments
that stimulate the ovaries to produce more eggs than usual, but there
are rare cases of OHSS occurring spontaneously.
Menstrual cycle
learn about this I
Sanjay
Hyperprolactinemia is a condition in which a person has higher-than-

normal levels of the hormone prolactin in the blood. The main function
of prolactin is to stimulate breast milk production after childbirth, so
high prolactin levels are normal in pregnancy.
Hypothyroidism in Pregnancy
● Hypothyroidism, wherein the thyroid gland produces an inadequate
amount of thyroid hormone, is a common disorder, particularly in

●
women of childbearing age.

● Hypothyroidism of the mother during pregnancy may result in
developmental delay in the child.
● Treatment of hypothyroidism requires thyroid hormone medication
LEVOTHYROXINE.
Anti-D immunoglobulin is administered routinely during the third

trimester of pregnancy if mother’s blood type is RhD negative. This is
because small amount of blood from baby can pass into mother during
this time.
If anti-D antibodies are detected in blood during pregnancy, there's a
risk that the baby will be affected by rhesus disease.
In D alloimmunization, an RhD-negative pregnant woman who is

exposed to fetal D positive red cells is at risk for developing anti-D
antibodies. Those diagnosed to have anti-D antibodies should be
managed based on measurement of the maternal blood antibody titers
and also Doppler ultrasonography of the fetal MCA.
What is female sterilization?

Female sterilization TUBECTOMY is a permanent procedure to prevent
pregnancy. It works by blocking the fallopian tubes. When women
choose not to have children, sterilization can be a good option.
Other methods are oral pills, contraceptives.
Menstural cycle
Itinestrogen
Estrogen dominant phase
to
Itg
5 days bleeding release egg
thicken endometrium
for fertilized egg
to attach
dominant phase
for uterus to start shedding
mensturation
prepare for another
10/22/2019 Acute Appendicitis in Pregnancy - Prognosis: Your Diagnosis | Medical Joyworks
Acute Appendicitis in Pregnancy exam FI

in
Even More Tummy Pain
Step 1: View clinicals meantime

A 27 year old primipara in her 30th week of pregnancy presents with pain in the lower
abdomen for 1 day, in association with anorexia and nausea. There was no history of fever,
vomiting, urinary symptoms or bowel symptoms.
Her pregnancy has been unremarkable so far, while her medical and surgical histories are
unremarkable. She is not on any drugs.
Her full blood count is signi cant for a leukocyte count of 13,500/mm3, with 70%
neutrophils. A urinalysis is within normal parameters.
Symphysial fundal height

normal position
of baby
Psoassign copessign
could indicate possible

appendix irritation
but not the test
used for appendicitis
Step 2: Order all relevant investigations
Ultrasound Abdomen Ordered
A single live intrauterine pregnancy compatible with 30 weeks of gestation is seen. The
appendix cannot be visualized. The liver, gallbladder, kidneys, and ovaries appear normal.
MRI Abdomen & Pelvis Ordered
The MRI scan reveals the presence of an enlarged appendix measuring 8mm in diameter,
with peri-appendiceal in ammation.
Diagnostic Laparoscopy Not ordered
GC + CT NAAT Not ordered
https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Acute-Appendicitis-in-Pregnancy/play 1/2
10/22/2019 Acute Appendicitis in Pregnancy - Prognosis: Your Diagnosis | Medical Joyworks
Step 3: Select appropriate management

Perioperative Antibiotics
Cesarean section
Appendectomy
Tocolytics
Score:
Replay case View explanations
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Copyright © Medical Joyworks LLC, 2010-2019. All rights reserved.
https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Acute-Appendicitis-in-Pregnancy/play 2/2
Dx Acute appendicitis casef
exam
1 Physical
Zfs
McBurney's point
Rousing's sign
2 CBC WBC
Us CT MRI
3 Imaging
McBurney's point palpate

this point if it illicits
pain that is a positive
sign for appendicitis
Complications
Toc 1 Antibiotic prophylaxis
2 Appendectomy
1 Rupture
peritonitis
causing
3 Analgesics
11/2/2019 Adrenocortical Tumor, Androgen Secreting - Prognosis: Your Diagnosis | Medical Joyworks
Adrenocortical Tumor, Androgen Secreting

Occult
Lian
case
2
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Learn More Learn More
Sanjay you
Step 1: View clinicals
work
have to
A 23 year old woman presents with excessive growth of hair over her face, chest, and
tennis
abdomen for 1 year. No other symptoms are present.
info
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symptoms Her medical, surgical, and family histories are unremarkable, while her menstrual cycles this
similar are regular, with menarche having taken place at the age of 12.
with mass
A complete blood count, serum electrolyte assay, liver and renal pro les, and fasting since
not
given
plasma glucose are all within normal parameters.
is
scale hirsutism
8 15 Mitsutis
16 25 n
Fits
25 SYEutism
https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Adrenocortical-Tumor-Androgen-Secreting/play 1/3

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Early Morning Total Testosterone Ordered
Early Morning Total Testosterone: 440 ng/dL (8-60)
Endocrine Pro le Ordered
Total Testosterone: 420 ng/dL (8-60)
Wasinger
DHEAS: 620 microg/dL (35-430)
Prolactin, TSH, FSH, LH, 17-OHP, Aldosterone: within normal parameters
Urinary Free Cortisol: within normal parameters
CT Abdomen Ordered
There is a homogenous solid mass measuring 2.0 x 1.3 x 1.8 cm in the left adrenal gland,
with regular margins. The attenuation of the mass is approximately 5 Houns eld Units
(HU). No other abnormalities are noted.
Percutaneous Fine Needle Aspiration Biopsy Ordered
The percutaneous ne needle aspiration biopsy reveals adrenal gland cells which are
morphologically benign.

Laparoscopic Adrenalectomy
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Glucocorticoids
Ketoconazole
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Clinical Sense Clinical Sense University Directory About
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Adreno cortical tumour migrant
forms on the
Doc androgen secreting
benign cortex exterior
of adrenal gland
Adrenal gland I Regulate metabolism

2 Regulate BP
function cortisol
3 Release
androgens
test to
Dx 1 Blood
tests measure hormone levels
t cortisol A androgen
2 Tissue biopsy
Us CT MRI
3 Imaging
antifungal antiandrogen
Dc 1 Ketoconazole
2 Adrenalectomy
if its
3 Lymph node
dissection I
only
malignant
4 Cancer therapies
11/1/2019 Androgen Insensitivity Syndrome - Prognosis: Your Diagnosis | Medical Joyworks
Androgen Insensitivity Syndrome

Changed
Innovative Essentials
primary amenorrhea
Work comfortably with our Adjustable Height Workcenters. Go from sitting to standing!
15 yrs of
menarche
InnovativeEssentials.com OPEN
no

A 16 year old girl is brought in by her parents, as she has not attained menarche. There are
no other complaints.
3
Her medical, surgical and family histories are unremarkable. She is not on any drugs.
I Have to
Mecognise
this case
with this
info
a
peris
cause
it's
Ultrasound Abdomen that's Ordered
The vagina is 4 cm in length, and blind ended. The uterus, fallopian tubes and ovaries
cannot be visualized. There are B/L solid masses in the inguinal region, ~3 cm in diameter
each, with peripheral cystic areas.
Karyotype Analysis Ordered
The karyotype is found to be 46 XY

male
Serum FSH and LH Ordered
LH: high normal

FSH: normal
https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Androgen-Insensitivity-Syndrome/play 1/2
11/1/2019 Androgen Insensitivity Syndrome - Prognosis: Your Diagnosis | Medical Joyworks
17alpha-hydroxylase levels Ordered
17alpha-hydroxylase levels are within normal parameters.
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Counselling
Gonadectomy
Androgens
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cased
Dx Androgen insensitivity
syndrome
individual who is a male 46 4 but is
resistant to androgen o
having female
traits
physical
Ites
hormo
respond to the androgen
i cells do not
3 Pelvic exam will show absence of

ovaries
uterus fallopian tubes
É Tx is based on whether the
patient want to be male

or female
health
mental
counselling for
Back "
PLAY EXPLANATION DISCUSSION
Expected
Cardiovascular System
1 View Clinicals 4
A 30 year old lady with a background of severe aortic stenosis presents at 38 weeks of
gestation of her first pregnancy complaining of mild persistent dyspnea.
She had no cardiac symptoms at conception, but started experiencing mild intermittent
dyspnea from the 2nd trimester onwards. She was otherwise normal when evaluated at 36
weeks.
fluid retention
scoretashowyou
how close you are
to labour this patient is not close
2 Investigate
to labor
Echocardiogram
The aortic valve area is 0.7 cm², with a transvalvular gradient of 60 mmHg. Le"
ventricular hypertrophy is noted, with a posterior wall thickness of 10 mm. Mild
diastolic dysfunction is present. The ejection fraction is 65%.
Cardiotocogram
The baseline heart rate is 150 bpm, with normal variability. Two accelerations are
seen; there are no decelerations.
Full Blood Count

WBC/DC: 8,000/mm3 (4,600-11,000)
Hb: 15.0 g/dL (11-18)
Platelets: 380,000/mm3 (150,000-400,000)
X-Ray Chest Order
3 Manage
Cesarean Section !
Diuretics !
Balloon Valvotomy
Endocarditis Prophylaxis
! Analysis
Investigation Your choice Result
Echocardiogram Ordered !
Cardiotocogram Ordered !
Full Blood Count Ordered !
X-Ray Chest Not ordered !
Management option Your choice Result
Cesarean Section Ordered !

Diuretics Ordered !
Balloon Valvotomy Not ordered !
Endocarditis Prophylaxis Not ordered !
⟲ PLAY AGAIN EXPLANATION

Back !
Expected
Cardiovascular System
Diagnosis and reasoning

This lady has presented with worsening dyspnea in late pregnancy.
Given her background of valvular heart disease, it is tempting to conclude that this must be
the underlying etiology.
However, it is important to appreciate that several other diseases can present in this manner
- particularly anemia, peripartum cardiomyopathy, pneumonia, and pleural e!usions.
One should also note that the physiological changes of pregnancy (particularly fluid
retention) can also give rise to dyspnea; this e!ect can be pronounced in patients with aortic
stenosis (AS), due to the high transvalvular pressure gradient.
She is not clinically anemic, while her full blood count shows a normal hemoglobin level; in
addition, her examination is negative for signs suggestive of pneumonia or an e!usion.
Note also the presence of fine bibasal crackles - this is suggestive of pulmonary edema
(which favors a cardiac origin for the dyspnea).
Her examination shows florid signs of Aortic Stenosis as expected. However, there is no
history of orthopnea or paroxysmal nocturnal dyspnea; her vital signs are stable; the jugular
venous pressure (JVP) is not elevated; and the apex beat is normal - i.e. she is not in clinical
heart failure (this also excludes peripartum cardiomyopathy).
Note that the mild bilateral pitting ankle edema is a nonspecific finding which can occur
even in healthy pregnant women.
Thus, her dyspnea appears to be mainly due to the pulmonary congestion or edema,
probably as a result of the physiological fluid retention of late pregnancy.
An echocardiogram to assess her current cardiac status is a must; this shows a good ejection
fraction and only mild diastolic dysfunction, supporting the clinical diagnosis.
It is important to also determine if fetal distress is present; the reactive cardiotocogram

(CTG) here is reassuring.
In general, the indications for chest x-rays in the pregnant population are similar to those in
non-pregnant women; note that the American Congress of Obstetricians and Gynecologists
(ACOG) state that X-ray exposure from a single diagnostic procedure does not result in
harmful fetal e!ects.
However, most guidelines on the management of heart disease in pregnancy agree that a
chest radiograph should only be obtained if other methods fail to clarify the cause of
dyspnea, cough, or other symptoms.
Thus, although a chest x-ray can be performed safely, it is probably unnecessary in this
clinical context.
Considering her immediate management, diuretic therapy will help relieve the fluid
overload; this should be combined with strict bedrest.
As the fetus is mature, it is fairly obvious that delivery is the best course of action, as this will
immediately relieve the stress on the maternal cardiovascular system.
Two important questions need to be answered though: what should the mode of delivery
be? And should endovascular intervention (i.e. a balloon valvuloplasty) be performed prior
to delivery?
The 2012 ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease
state that Aortic valvuloplasty may be considered in pregnant women with severe AS before
labor and delivery if heart failure has developed or if syncope has occurred; thus, this
procedure is probably not indicated in this patient.
The mode of delivery is also a tricky question. The general guidance over the years has been
that labor is not contraindicated in severe AS; and that an assisted second stage is important
to avoid the Valsalva maneuver.
However, the most recent guideline of the European Society of Cardiology (ESC) advocates
Cesarean delivery under general anesthesia in pregnant women with severe AS. Regional
anesthesia in these patients is controversial as this may cause a decrease in cardiac preload
and a"erload, with deleterious e!ects.
Considering this patient, note that she is a primipara - i.e. her labor may very well be
prolonged. Thus, most clinicians are likely to opt for a Cesarean delivery.
Endocarditis prophylaxis is not recommended in patients with AS, even when undergoing
Cesarean section or vaginal delivery.
Discussion
Valvular heart disease is a high-risk state complicating about 1% of all pregnancies
worldwide; the hemodynamic changes associated with pregnancy, labour and the
postpartum period contribute to make the management extremely challenging.
The remainder of this discussion focuses on Aortic Stenosis (AS) in pregnancy.
In the developed world, AS in women of childbearing age is usually due to bicuspid aortic
valves. Rheumatic valvular disease is an important cause in the developing world; however,
note that this is almost always associated with concomitant mitral valve lesions.
Note that AS is graded as 'mild', 'moderate', or 'severe' based on the valvular area,
transvalvular pressure gradient and jet velocity; these criteria are the same in both pregnant
and nonpregnant individuals.
When considering the pathophysiology of AS in pregnancy, two key points need to be kept in
mind:
- The hypertrophied le" ventricle is dependant on the cardiac preload to maintain output.
However, catastrophic changes in preload usually do not occur in pregnancy - thus sudden
cardiac failure is rather unlikely.
- The increase in circulatory volume and heightened le" ventricular outflow gradient
(secondary to an increase in cardiac output) mainly a!ects the le" ventricle; the le" atrium
and pulmonary arteries are relatively mildly a!ected - thus pulmonary congestion is usually
not pronounced.
In summary, the hemodynamic changes of AS in pregnancy are fairly straightforward and

predictable, allowing an element of reassurance when managing these patients.
Important cardiac complications which may occur in pregnancy include heart failure,
arrhythmias and ischemic events; obstetric complications include preeclampsia, premature
birth, and small-for-gestational-age births.
Note that the o!spring of women with congenital aortic stenosis or bicuspid aortic valves
are at risk of having a congenital cardiac lesion.
These patients should be managed by a multidisciplinary team including an obstetrician

and a cardiologist; the management should start prior to conception itself.
They should be counselled on the nature of the disease, the maternal and fetal risks
associated with pregnancy, and on the therapeutic measures which may become necessary.
Women with mild to moderate AS, or asymptomatic severe AS with good cardiac function
tend to tolerate pregnancy well, and can be advised to go ahead with conception.
Women with symptomatic severe AS (i.e. associated with angina, syncope, or symptoms of
heart failure) should receive contraceptive cover; the valvular lesion should be treated prior
to pregnancy.
Note that some women may only be diagnosed with AS a"er becoming pregnant; if
symptomatic severe AS is present, serious consideration should be given towards
termination of the pregnancy, and treatment of the lesion (following which the patient can
attempt to become pregnant again).
The subsequent management during pregnancy is highly individualised and depends on the
cardiac status and presence of symptoms.
Patients who develop mild symptoms can be managed conservatively by means of bedrest,
oxygen, treatment of exacerbating factors, beta‐blockers and cautious diuresis where
volume overload is present.
Patients with severe symptoms may require intervention. Balloon valvotomy can reduce the
risks of gestation, labor, and delivery and avoid the risks of valve replacement; this is
counterbalanced by the risk of iatrogenic aortic regurgitation, and the fact that restenosis is
common.
Surgical aortic valve replacement may need to be considered in severely symptomatic

women with valve calcification or unfavorable anatomy.
The fetuses of women with congenital AS or bicuspid valves should undergo fetal
echocardiography at around 20 to 22 weeks of gestation.
The timing and mode of delivery depends on both obstetric factors such as the Bishop
score, fetal well-being, and lung maturity, as well as the patient's cardiac status.
However, in general, in non severe aortic stenosis, pain free assisted vaginal delivery is
preferred; delivery can be induced if the cervix is not favorable - however prolonged labor
should be avoided.
Note that epidural anesthesia may be considered for pain relief - but should be used with
caution as it may lower the preload, resulting in a sudden drop in cardiac output.
If the patient has severe symptomatic AS, Cesarean delivery is o"en preferred; this is ideally
performed under general anesthesia.
Note that delivery at a center equipped to manage high-risk heart disease is recommended
for patients with moderate to severe aortic stenosis or a significantly dilated aorta.
Endocarditis prophylaxis is not indicated in these patients, regardless of the mode of

delivery.
A"er delivery, these patients should receive counselling on the risks of future pregnancies;
permanent contraception should be o!ered to women who have completed their families.
Take home messages

1. The obstetric management of women with AS should start prior to conception.
2. A multidisciplinary approach to management is critical for a good outcome.
3. Patients with severe disease should be managed at a centre experienced in high-risk heart
disease.
References
1. 1 Cardiol Clin. 2012 Aug;30(3):369-81. doi: 10.1016/j.ccl.2012.04.004. Epub 2012 May 30,
Valvular heart disease and pregnancy,Traill TA.
2. 2 Heart. 2007 May;93(5):552-8. Epub 2006 Aug 11,Pregnancy in women with valvular
heart disease,Stout KK, Otto CM.
3. 3 Eur Heart J. 2011 Dec;32(24):3147-97. doi: 10.1093/eurheartj/ehr218. Epub 2011 Aug
26. ESC Guidelines on the management of cardiovascular diseases during pregnancy:
the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the
European Society of Cardiology (ESC),European Society of Gynecology (ESG);
Association for European Paediatric Cardiology (AEPC); German Society for Gender
Medicine (DGesGM), Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R,
Ferreira R, Foidart JM, Gibbs JS, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas
AH, Morais J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW,
Schaufelberger M, Seeland U, Torracca L; ESC Committee for Practice Guidelines.
4. 4 Curr Cardiol Rep. 2006 Mar;8(2):83-9,Valvular heart disease in pregnancy,Scirica BM,
O'Gara PT.
5. 5 J Am Coll Cardiol. 2008 Sep 23;52(13):e1-142,2008 focused update incorporated into
the ACC/AHA 2006 guidelines for the management of patients with valvular heart
disease: a report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for
the management of patients with valvular heart disease). Endorsed by the Society of
Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and
Interventions, and Society of Thoracic Surgeons,Bonow RO, Carabello BA, Chatterjee K,
de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT,
O'Rourke RA, Otto CM, Shah PM, Shanewise JS; American College of
Cardiology/American Heart Association Task Force on Practice Guidelines.
6. 6 Bol Asoc Med P R. 2008 Oct-Dec;100(4):55-9,Valvular heart disease in pregnancy: a
review of the literature,Martinez-Diaz JL.
PLAY DISCUSSION
Doc
casef
worsening dyspnea
late
during pregnancy
to fluid retention
secondary
Doc I CBC
tests 2 Echocardiogram
monitors
3 Carditocogram
fetal HR
uterine
contractions
Toc 1 Diuretics
2 C section
11/1/2019 Ectopic Pregnancy - Prognosis: Your Diagnosis | Medical Joyworks
Ectopic Pregnancy
5
Out of place

A 29 year old woman presents with severe pain in the lower abdomen and right iliac fossa
for 2 days.
A week ago she presented with pelvic pain and vaginal bleeding, and was diagnosed with a
complete miscarriage as her urine hCG test was positive and the ultrasound abdomen
D
showed an empty uterus.
Her last regular menstrual period was 6 weeks ago. A repeat urine hCG test is positive.
iliac fossa
fight
Legendairy Milk
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Serum beta-hCG Ordered
The serum beta-hCG level is 1500 IU/L.
Transvaginal ultrasound Ordered
A right sided adnexal mass measuring 2 x 2.5 x 2 cm is noted. There is no evidence of

cardiac activity. The uterus is empty. There is no free uid in the pelvis.
https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Ectopic-Pregnancy/play 1/2
11/1/2019 Ectopic Pregnancy - Prognosis: Your Diagnosis | Medical Joyworks
Chest X-Ray Ordered
The x-ray appears normal.
Full Blood Count Ordered
WBC/DC: 8,000/mm3 (4,600 - 11,000)

Hb: 12.2 g/dl (11.5 - 18.5)
Platelets: 324,000/mm3 (150,000 - 450,000)
Tbilisi to New Delhi Tbilisi to Mumbai

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IM Methotrexate
Oral Doxycycline
Emergency Laparotomy
S/C Morphine
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https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Ectopic-Pregnancy/play 2/2
Do
Ectopic Casey
pregnancy
Doc 1 Pelvic exam
tests
2 Speculum exam
3 B HCG
4 Us
Tx 1 Methotrexate M
2 Laparoscopic surgery
Back "
More Chronicity
Female Reproductive System & Breast
1 View Clinicals
6
A 25 year old lady presents with pelvic pain of 2 years duration, which worsens with
menstruation.
dysmenta
Her periods became heavier during the last 6 months, while she also experienced marked
dyspareunia.
Her medical and gynecological histories are otherwise unremarkable. She married 6 months
ago, and is currently planning a pregnancy.
yes
Sanjay this
case is
hard
to recognise
so use this
into
Eff
2 Investigate
Urine culture + ABST Order
uterus aimed
towards rectal
Pelvic ultrasound
backwards
Retroverted uterus of normal size. Ovaries attached to each other, behind uterus. No
other abnormalities noted.
CA-125 Order
Cervical swab + GC/CT NAAT

Negative for both gonorrhea and chlamydia.
3 Manage
Antispasmodics
Antibiotics
Oral Contraceptive Pills
Laparoscopic ablation !
! Analysis
Urine culture + ABST Not ordered !

Pelvic ultrasound Ordered !
CA-125 Not ordered !
Cervical swab + GC/CT NAAT Ordered !
Antispasmodics Not ordered !

Antibiotics Not ordered !
Oral Contraceptive Pills Not ordered !
Laparoscopic ablation Ordered !

Back !
More Chronicity

Chronic pelvic pain is a common presenting complaint in women of reproductive age.
Despite the traditional association with gynecology, it is important to appreciate that a
number of non-gynecological causes may also present in this manner.
In this patient, the presence of cyclic worsening of pain, heavy periods and dyspareunia is
admittedly more in favor of a gynecologic etiology, with endometriosis, adenomyosis, pelvic
inflammatory disease (PID) and fibroids being important diagnoses to consider.
Note both interstitial cystitis and irritable bowel syndrome can also present with cyclic pain,
and are frequent enough to warrant consideration here. However, the absence of other
supportive symptoms argues against these diagnoses.
Examination shows the uterus to be normal in size, making adenomysis (where the uterus is
typically bulky and enlarged) less likely. In addition, the absence of palpable pelvic or
abdominal masses is against fibroids (but does not exclude this possibility).
The presence of tenderness and nodularity in the pouch of Douglas provides an important
clue - this is strongly suggestive of endometriosis. Note also that endometriosis is the most
common cause of chronic pelvic pain in this age group.
Tenderness in the pouch of Douglas may also occur in PID - however, the absence of
cervicitis or a purulent vaginal discharge argue against this diagnosis (but do not definitively
exclude it).
Transvaginal ultrasonography is the preferred first line imaging modality in patients with
suspected endometriosis, and in this patient may also be useful in excluding the other
di!erentials. The sonographic findings here definitively exclude fibroids and adenomyosis.
Note that pelvic endometriotic deposits are extremely di!icult to visualize via
ultrasonography. However, the fact that the ovaries are displaced and attached to each
other provides indirect evidence in support of endometriosis, as this is suggestive of pelvic
adhesions (which are a common accompaniment).
While the evidence so far is strongly in favor of endometriosis, it should not be forgotten that
chronic PID may also result in intraperitoneal adhesions. Thus, there is justification in
excluding the two most common pathogens implicated in PID - gonorrhea and chlamydia.
In conclusion, given the strong clinical and imaging evidence, this is most likely pelvic
endometriosis indeed.
Note that a urine culture is not of particular benefit in this patient - especially considering
that interstitial cystitis is sterile.
In addition, CA-125 is not of diagnostic value here; note also that peritoneal irritation due to
endometriotic deposits can result in mild elevation of CA-125 levels.
While oral contraceptive pills (OCPs) are the first line treatment in endometriosis, these are
not an option in this patient, who is attempting to conceive.
Laparoscopy and ablation of the endometriotic deposits is perhaps the best option here.
This should be performed by an experienced operator, in view of the pelvic adhesions.
Note that antibiotics and antispasmodics are not indicated in her management.
Discussion
Endometriosis is the presence of endometrial tissue outside the uterine cavity, primarily on
the ovaries, pelvic peritoneum, uterosacral ligaments and pouch of Douglas.
Endometrial deposits may also be found in other pelvic organs such as the bladder and
bowel; in extrapelvic locations such as the liver, umbilicus and surgical scars, and even as far
away as the lungs.
It is a very common gynecological disorder, a!ecting an estimated 6% to 10% of women of

reproductive age.
The exact etiology of endometriosis is unclear, although several theories have been
postulated. The most commonly accepted is that of retrograde reflux of menstrual tissue.
Prolonged exposure to endogenous estrogen (e.g. early menarche, and shorter menstrual
cycles) is known to increase the risk for endometriosis. In addition, twin and family studies
have suggested a genetic component to the disease.
Common presenting symptoms include pelvic pain, dysmenorrhea, deep dyspareunia and
back pain; in addition, painful micturition and defecation may occasionally occur. Note
however that a significant number of patients are completely asymptomatic.
It should also be appreciated that subfertility is a major problem in these patients; an

estimated 21% of women undergoing investigation for infertility are found to have the
disease.
Examination is o"en unremarkable; positive findings include tender nodularity of the

posterior vaginal fornix, tender adnexal masses, a fixed retroverted uterus, or uterine
motion tenderness.
Transvaginal ultrasonography is the imaging modality of choice in these patients. However,

this is mainly sensitive for uterosacral lesions and endometriomas; it does not accurately
identify peritoneal lesions.
Direct visualization of the pelvis at laparoscopy is the gold standard of diagnosis;

histological confirmation is generally unnecessary.
In patient who are not aiming to conceive, empirical medical treatment (without
laparoscopic confirmation) is usually acceptable. However, if pregnancy is desired, surgical
management is usually necessary.
Medical therapeutic options include OCPs, progestogens (e.g. medroxyprogesterone

acetate), GnRH agonists, androgenic agents (e.g. danazol) and antiprogestogens (e.g.
gestrinone). In addition, analgesics (NSAIDs) are of symptomatic value.
OCPs and progestogens are considered first line treatment agents, while GnRH agonists and
danazol are usually considered at a later point, due to their cost and side e!ect profiles.
In particular, GnRH agonist usage results in deterioration of bone mineral density (BMD).
Thus, it is prudent to commence add-back therapy with estrogen and progestogen in these
patients.
Note also that the levonorgestrel intrauterine system (LNG-IUS) can also be used in the
treatment of pelvic pain and dysmenorrhea associated with endometriosis.
Surgical options include laparoscopic excision or ablation of endometriotic deposits on the

peritoneum; excision, drainage, or ablation of endometriomas; adhesiolysis; resection of
rectovaginal nodules; and interruption of neural pathways (eg: presacral neurectomy).
Note however that symptoms usually recur a"er discontinuation of medication, or following
conservative surgical treatment.
When medical management has failed, definitive surgical management (hysterectomy and
bilateral salpingo-oophorectomy) may be considered in women who do not desire future
fertility.
Take home messages

1. Endometriosis is the most common cause of chronic pelvic pain in women of reproductive
age.
2. Ultrasonography is the imaging modality of choice, although the sensitivity varies by type
of endometriotic lesion.
3. While laparoscopy is the gold standard for diagnosis, this may be avoided in patients
suitable for pure medical management.
4. Endometriosis tends to recur following cessation of medication, or following conservative
surgery.
References
1. NEJM: Endometriosis (2010)
2. AFP: Chronic Pelvic Pain in Women (2008)
3. BMJ: Endometriosis (Feb 2007)
4. AFP: Diagnosis and Management of Endometriosis (August 2006)
5. NEJM: Treatment of Endometriosis (2001)
PLAY DISCUSSION
Doc Endometriosis cased
Dx 1 Pelvic exam
tests 2 Speculum exam
3 Hysteroscopy
4 Hysterosalpingogram
5 Laparoscopic gold
6 Uls
TI 1 GnRH agonists
contraceptives
2 Oral
GOPN
3 Progestin therapy inficated
surgeries
4 NSAIDs is
pt
best 5 Surgical
resection of
IÉÉ
imply
endometrial to
get
the his
6 Hysterectomy
fog
Back "
Fearsome
igny
1 View Clinicals
A 23-year-old woman presents with a painless lump in her right breast. She discovered the
lump a few days ago, when doing a breast self-examination. She has no other symptoms.
There is no history of trauma to the breast, or of previous breast lumps.
Her medical and surgical histories are unremarkable. She is not on any medications. Her
family history is also unremarkable. She is nulliparous. Her menarche was at the age of 13
and her menstrual cycles are regular, with a 28-day duration. She is not on contraceptives
currently.
2 Investigate
Breast ultrasound
There is a well-circumscribed ovoid mass in the upper outer quadrant of the right
breast. The mass is 1.7 x 1.9 cm in size, with a sharp and smooth contour and uniform
hypoechogenicity.
The le! breast is sonographically normal.
Mammography Order
MRI breasts Order
Core needle biopsy

There is hyperplasia of the epithelial and stromal components and proliferation of the
intralobular stroma with compression of the epithelium (i.e., a peri-canalicular
pattern). There is no cytological atypia and the basement membrane is intact.
3 Manage
O!er observation (watchful waiting) !
O!er surgical excision !
O!er mastectomy
O!er hormone therapy
Score: 100% View Analysis

Back "
Fearsome
Female Reproductive System & Breast sameas
1 View Clinicals
case
ignorabove
A 23-year-old woman presents with a painless lump in her right breast. She discovered the
lump a few days ago, when doing a breast self-examination. She has no other symptoms.
There is no history of trauma to the breast, or of previous breast lumps.
Her medical and surgical histories are unremarkable. She is not on any medications. Her
family history is also unremarkable. She is nulliparous. Her menarche was at the age of 13
and her menstrual cycles are regular, with a 28-day duration. She is not on contraceptives
currently.
2 Investigate
Breast ultrasound
There is a well-circumscribed ovoid mass in the upper outer quadrant of the right
breast. The mass is 1.7 x 1.9 cm in size, with a sharp and smooth contour and uniform
hypoechogenicity.
The le! breast is sonographically normal.
Mammography Order
MRI breasts Order
Core needle biopsy

There is hyperplasia of the epithelial and stromal components and proliferation of the
intralobular stroma with compression of the epithelium (i.e., a peri-canalicular
pattern). There is no cytological atypia and the basement membrane is intact.
3 Manage
O!er observation (watchful waiting) !
O!er surgical excision !
O!er mastectomy
O!er hormone therapy
! Analysis
Breast ultrasound Ordered !

Mammography Not ordered !
MRI breasts Not ordered !
Core needle biopsy Ordered !
O"er observation (watchful waiting) Ordered !

O"er surgical excision Ordered !
O"er mastectomy Not ordered !
O"er hormone therapy Not ordered !

Back !
Fearsome

The young woman with a breast lump is a common presentation in primary care. The
majority of such cases are benign in nature, with key possibilities being fibroadenomas,
fibrocystic disease, ductal ectasia, intraductal papillomas, phyllodes tumors, trauma, and
infection.
However, the possibility of a malignancy should never be disregarded, especially if there is a

family history of breast cancer at a younger age; and the initial approach should be similar
to that of any other breast lump, i.e., via the "triple test" – clinical evaluation, imaging, and
pathological studies.
Here, the patient's family history is negative for breast malignancies, while examination
shows the lump to be discrete, smooth, rubbery, and widely mobile. These findings favor a
benign etiology. In particular, the high mobility of the lump is suggestive of a fibroadenoma.
Imaging should be the next step. Given her age, breast ultrasound is preferable. Here, this
shows the lump to be oval, well-circumscribed, with a sharp and smooth contour, and
uniformly hypoechogenic. These findings are further suggestive of a fibroadenoma.
Note that breast tissue tends to be highly dense in young women. This tends to limit the
usefulness of mammography. Furthermore, magnetic resonance imaging (MRI) of the breast
is expensive, and in this clinical context, unlikely to yield additional information of
diagnostic value.
Pathological studies are the final step. Core needle biopsy is a suitable option in this regard.
This provides histological confirmation that the mass is a fibroadenoma, clinching the
diagnosis. The biopsy also shows this to be a simple fibroadenoma
Since this is a simple small fibroadenoma, she can be managed via watchful waiting.
However, the option to excise the lump should also be o!ered, and her wishes respected.
Mastectomy is completely unnecessary. The is no role for hormone therapy in her
management.
Discussion
Fibroadenomas are the most common benign tumor of the breast. While they can occur at
any age, most cases are encountered in adolescents and young women between 20-30 years
of age.
Fibroadenomas arise from the the terminal duct-lobular units; and are thus composed of
both epithelial and stromal elements. They are believed to be a result of aberrant breast
growth – i.e., they are hyperplastic lesions rather than true neoplasms. They usually first
form during menarche, as this is a time where both stromal and epithelial cells proliferate.
Fibroadenomas are stimulated by estrogen and progesterone. They can fluctuate in size
throughout the menstrual cycle; they o"en become larger during pregnancy and lactation;
and they tend to undergo atrophic changes during menopause. Malignant transformation is
rare, with a reported incidence of just 0.002-0.0125%.
Genetic factors have not been linked to the development of fibroadenomas. The age of
menarche, age of menopause, and use of hormonal therapy have not been implicated as
risk factors either. Interestingly, increased parity and a higher body mass index (BMI) appear
to be protective.
Most fibroadenomas are detected incidentally, either during breast self-examination or

routine clinical examination. They present as solitary breast lumps that are non-tender,
discrete, clearly defined, smooth, rubbery, and highly mobile. Between 10-25% of these
women develop multiple fibroadenomas, which may present simultaneously, or be
discovered over a period of several years.
As with any other breast lump, the evaluation of these patients should follow the triple test.
This involves clinical evaluation, imaging, and pathological studies.
Most guidelines agree that women <30 years of age should undergo breast ultrasound, as
the density of breast tissue in this age group limits the utility of mammography. Most
guidelines also agree that mammography is preferable in women ≥40 years of age. In
women between 30-39 years of age, di!erent guidelines recommend either ultrasound
alone; mammograpy alone; or either of these.
Both fine needle aspiration cytology (FNAC) and core needle biopsy are suitable
pathological studies. Both provide su!icient information for diagnosis. However, core
needle biopsy provides additional histological information, allowing for determination as to
whether the fibroadenoma is simple or complex.
Histologically, a fibroadenoma is said to be "complex" if any of the following pathological

features are present: epithelial calcifications, papillary apocrine metaplasia, sclerosing
adenosis, or cysts >3 mm in size. Complex fibroadenomas are associated with an elevated
risk for breast cancer.
A significant minority of fibroadenomas resolve spontaneously. Therefore, many authorities

recommend that simple small (<2 cm in diameter) fibroadenomas be managed via watchful
waiting. These patients should be followed up at regular intervals (between 6 months to 2
years).
Fibroadenomas that are >2 cm in size, which show rapid growth, which show complex
histological features, or which are encountered in women ≥35 years of age should be
excised. Even otherwise, excision should be performed if the patient wishes to have the
lump removed.
Open surgery has been the traditional method of excision, although endoscopic
lumpectomy is also performed. Cryoablation is an alternative for simple fibroadenomas.
Take home messages

1. Fibroadenomas are the most common benign breast neoplasm. Malignant
transformation is rare.
2. Breast ultrasound is generally preferred in younger women, as the density of breast
tissue limits the utility of mammography.
3. Both FNAC and core needle biopsy allow for pathological diagnosis. However, core
needle biopsy also allows for determination if the fibroadenoma is simple or complex.
4. Small simple fibroadenomas should be managed via watchful waiting. Fibroadenomas
that are large, increasing in size, complex, or found in women ≥35 years of age should
be excised.
References
1. STACHS A, STUBERT J, REIMER T, HARTMANN S. Benign Breast Disease in Women.
Dtsch Arztebl Int [online] 2019 Aug 9, 116(33-34):565-574 [viewed 13 November 2020]
Available from: https://pubmed.ncbi.nlm.nih.gov/31554551
2. AMIN AL, PURDY AC, MATTINGLY JD, KONG AL, TERMUHLEN PM. Benign breast disease.
Surg Clin North Am [online] 2013 Apr, 93(2):299-308 [viewed 13 November 2020]
Available from: https://pubmed.ncbi.nlm.nih.gov/23464687
3. GREENBERG R, SKORNICK Y, KAPLAN O. Management of Breast Fibroadenomas J Gen
Intern Med [online] 1998 Sep, 13(9):640-645 [viewed 22 August 2016] Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497021
4. BRENNAN M, HOUSSAMI N, FRENCH J. Management of benign breast conditions. Part
2--breast lumps and lesions. Aust Fam Physician [online] 2005 Apr, 34(4):253-5 [viewed
13 November 2020] Available from: https://pubmed.ncbi.nlm.nih.gov/15861746
5. ASLAM HM, SALEEM S, SHAIKH HA, SHAHID N, MUGHAL A, UMAH R. Clinico-
pathological profile of patients with breast diseases. Diagn Pathol [online] 2013 May
9:77 [viewed 22 August 2016] Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23659667
6. CERRATO F, LABOW BI. Diagnosis and Management of Fibroadenomas in the
Adolescent Breast Semin Plast Surg [online] 2013 Feb, 27(1):23-25 [viewed 04
September 2016] Available from:
PLAY DISCUSSION
11/1/2019 Fibroids, Red degeneration - Prognosis: Your Diagnosis | Medical Joyworks
Fibroids, Red degeneration

Dilemma
case 5 Best Herbs for a Weak Strea

Aqeds Doctors Reveal 1 Weird
UP Compound to Improve Weak
came
g
Urine Flow in Surprising Clinical
exam
in Study.
Nutreance

A 28 year old lady who is 26 weeks pregnant presents with severe right sided abdominal
pain for 1 day associated with nausea and vomiting.
This is her rst pregnancy. Her medical and gynecological histories are unremarkable.
Dies
esta
exam
Vaginal
5 Best Herbs for a Weak Strea

Doctors Reveal 1 Weird
Compound to Improve Weak
Urine Stream in Surprising Clinical
Study.
Nutreance
https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Fibroids-Red-degeneration/play 1/3
11/1/2019 Fibroids, Red degeneration - Prognosis: Your Diagnosis | Medical Joyworks
WBC/DC: 13,400/mm3
N: 75% L: 20%
Hb: 12.9 g/dl

Hct (PCV): 38%
Platelets: 336,000/mm3
Urinalysis Ordered
Pus cells: 1 - 2 /hpf

RBC: nil/hpf
pH: 5.5
Nitrite dipstick test: negative
Cardiotocogram Ordered
The cardiotocogram shows a fetal heart rate within normal parameters. There is no
evidence of uterine contractions.
Abdominal + Pelvic Ultrasound Ordered
A 6cm x 6cm echogenic mass is noted in the anterior wall of the uterus, corresponding to
We
the area of abdominal tenderness. No urinary calculi are noted, while the appendix is not
visualized. Both ovaries appear normal, with satisfactory blood ow.
Tbilisi to New Delhi BOOK NOW

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Analgesics
Antibiotics
Urgent cesarian section
Myomectomy
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Calculate score
Contact
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https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Fibroids-Red-degeneration/play 2/3
fibroids
asf
Doc Leiomyoma came
Dx Pelvic exam
I
tests
exam
2 Speculum
be
CBC anemia may
3 blood loss
found due to
4 Ultrasound
not for this pt
5 Hysteroscopy bar she
preg
Tx 1 Iron supplements
HUME 2 Hysterectomy for this pt

potbez she preg
3 Uterine embolization
4 Myomectomy femoral
fibroids
Ight
for fibroids
5 Endometrial ablation
heat
Back "
Hot Chest 2
Female Reproductive System & Breast ignore
1 View Clinicals
q
A 30 year old woman presents with redness, pain, and worsening swelling of her right breast
for 2 weeks.
There is no history of fever, itching, or trauma to the a!ected breast. Treatment with a 7-day
course of oral antibiotics yielded no visible response.
Her medical history is unremarkable, and there is no family history of malignancy. Her first
child was born 7 months ago, and is still being breastfed.
2 Investigate
Complete Blood Count
WBC/DC: 8,000/mm3 (4,600-11,000)
N: 70% L: 25%
Hb: 12 g/dL (11-18)
Plt: 300,000/mm3 (150,000-450,000)
C-Reactive Protein
C-reactive protein: 3.0 mg/L (normal: <6)
Ultrasound Breasts
The ultrasound scan of the right breast reveals skin thickening. No hypoechogenic or
hyperechogenic lesions are noted. In the right axilla, a single central lymph node is
enlarged. The le" breast and axilla appear normal.
Mammogram Right Breast Order
3 Manage
IV Antibiotics
Urgent Oncology Referral !
Breastfeeding Counselling
Surgical Drainage
! Analysis
Complete Blood Count Ordered !

C-Reactive Protein Ordered !
Ultrasound Breasts Ordered !
Mammogram Right Breast Not ordered !
IV Antibiotics Not ordered !

Urgent Oncology Referral Ordered !
Breastfeeding Counselling Not ordered !
Surgical Drainage Not ordered !

Back !
Hot Chest 2

This young lady has presented with pain, erythema, and swelling of her right breast, i.e.
features suggestive of an inflammatory condition.
Given that she is lactating, key possibilities include lactational mastitis, cellulitis of the
breast, or a breast abscess.
However, examination reveals several disconcerting findings: di!use enlargement and

erythema of the breast, thickening of the overlying skin, and a single non-tender lymph
node in the ipsilateral axilla.
Note that both lactational mastitis and breast abscesses usually involve only a single
quadrant of the breast, although cellulitis may span several quadrants.
In addition, while any infectious process can result in loco-regional lymphadenopathy, this
is typically tender in nature.
Furthermore, the above etiologies are frequently accompanied by fever, while a leukocytosis
and elevated C-reactive protein (CRP) levels are usually seen; however this patient's
complete blood count and CRP assay are completely normal.
Last but not least, note that she has been through a full course of antibiotics; one would
expect both lactational mastitis and cellulitis to demonstrate some degree of improvement,
although a breast abscess is unlikely to resolve without drainage.
Thus, none of these diagnoses properly fit the clinical findings and basic investigations; this
forces us to consider a far more unpleasant possibility: Inflammatory Breast Cancer (IBC), an
uncommon (but highly aggressive) malignancy which can mimic an inflamed breast.
The short duration of symptoms, di!use breast enlargement, and skin thickening seen here
is typical of IBC, as is the presence of painless lymphadenopathy; in fact, these findings are
su!icient to clinically diagnose the condition. However, histopathologic confirmation should
be obtained later on.
An urgent ultrasound scan of the breasts is a good next step; this further confirms the clinical
findings, while also definitively excluding a breast abscess.
She should be referred to an oncologist as soon as possible. Note that there is no point in
administering intravenous (IV) antibiotics; nor is breastfeeding counseling required.
Surgical drainage would have been indicated in the event of an abscess.
Discussion
Inflammatory Breast Cancer (IBC) is an uncommon, highly aggressive form of breast cancer
which mimics an inflamed breast; it is considered a special type of Locally Advanced Breast
Cancer (LABC).
While only 1% to 6% of cases of breast cancer diagnosed in the United States are due to IBC,
the condition causes 8% to 10% of all breast cancer related deaths.
A!ected patients tend to be relatively young (e.g. pre- or perimenopausal), as compared to

women with non-inflammatory breast cancer; the condition may occur during pregnancy
and lactation.
Note that the incidence of IBC appears to be higher in women of African-American and Asian
Pacific Islander ethnicities.
The American Joint Committee on Cancer (AJCC) defines IBC as a composite

clinicopathologic entity characterized by di!use edema (peau d'orange) and erythema over
the majority (one third or more) of the breast, o"en without an underlying mass.
The term 'inflammatory' is in fact a misnomer; while the disease does visually mimic an
acute inflammatory breast by demonstrating erythema, warmth, edema, and induration,
microscopy reveals cancer cells rather than an inflammatory infiltrate.
The above phenomena are a result of pathologic plugging of the dermal lymphovascular
spaces by tumor emboli; this is termed "dermal lymphatic invasion", and is a histological
hallmark of IBC.
Note also that while the genetic basis of the condition is still poorly understood, there
appear to be several key di!erences which di!erentiate it from non-inflammatory LABC. In
particular, more than half of these patients exhibit estrogen receptor (ER) negative tumors,
while approximately 33% manifest triple-negative tumors.
Known risk factors for IBC include a family history of breast cancer, and an elevated body
mass index (BMI).
Note also that according to the Tumor-Node-Metastases (TNM) classification system, IBC is
classified as a T4d tumor (.e.g Stage IIIb).
Changes in the skin overlying the a!ected breast are the first sign of IBC; these can range
from any degree of erythema, to an angry red or purple discoloration.
As the condition advances, a peau d'orange appearance may be seen in the dependent part
of breast, and later, over the entire organ.
Patients may also complain of a sensation of heaviness, or 'aching' or 'burning' sensations in

the a!ected breast; flattening, retraction, crusting or blistering of the nipple may also be
seen.
It should also be appreciated that up to 30% of patients with IBC may not have a palpable
breast mass.
Unfortunately, it is extremely easy to mistake the above changes as being due to an

inflammatory etiology, resulting in delayed diagnosis.
However, IBC typically involves more than a third of the breast; as a rule of thumb, most
inflammatory etiologies usually involve only a segment, or specific region.
In addition, the absence of systemic inflammatory features such as fever, leukocytosis, or

elevated acute phase reactants (C-Reactive Protein and ESR) may provide a further clue.
In certain patients, it may also be necessary to di!erentiate between IBC and a neglected
non-inflammatory LABC presenting at a late stage.
A history of rapid enlargement of the a!ected breast, along with the absence of an
underlying mass is a strong hint towards the former diagnosis; in addition, non-
inflammatory breast cancers are usually painless.
Note that the International Expert Panel on Inflammatory Breast Cancer has formulated
criteria for the diagnosis of IBC; these state that that IBC is a clinical diagnosis, although
subsequent pathological confirmation is essential.
A core needle biopsy of the breast is the preferred histopathological study, with the aim of
confirming the presence of an invasive carcinoma; this will also aid in determination of
hormone receptor status, and HER2 positivity.
Skin punch biopsies may also be obtained, so as to demonstrate dermal lymphatic invasion;
while this is pathognomonic of the condition, it can only be detected in 50% to 75% of
patients.
At present, imaging studies are not part of the diagnostic criteria; this is due to the lack of
data on which radiological signs are most specific for IBC.
That said, all patients with suspected IBC should nonetheless undergo mammography
and/or an ultrasound of the breasts and regional lymph nodes.
Mammography may reveal skin thickening, trabecular and stromal thickening and markedly
increased breast density. However, the diagnostic yield is o"en poor in younger women, due
to the dense breast tissue, while breast tenderness may make the procedure technically
di!icult.
Ultrasonography may demonstrate skin thickening, and axillary lymphadenopathy; in ~95%

of a!ected breasts, parenchymal architectural distortions can be detected.
Last but not least, it is essential to perform a metastatic workup in all patients diagnosed
with the disease.
The treatment of IBC will vary depending on the staging of the patient and the treatment
protocols of the units involved; however, there is a general consensus that the risk of loco-
regional and distant recurrence is too high to justify immediate mastectomy.
Thus, trimodal therapy is usually employed, e.g. initial neoadjuvant chemotherapy followed
by a mastectomy with axillary clearance, and subsequent radiotherapy to the chest wall and
regional lymph nodes. Some women may also receive further hormonal modulation.
A"er the course of treatment is complete, the American Society of Clinical Oncology (ASCO)
recommends a brief physical examination every 3 to 6 months, as well as an yearly
mammogram of the contralateral breast.
As mentioned earlier, IBC is highly aggressive; at the time of diagnosis, a significant number
of patients will have local and/or distant metastases, and despite multimodal therapy,
survival is poor.
Overall, modern treatment techniques have resulted in a 5-year survival rate of 40%, and 10
year survival rate of 33%.
Take home messages

1. In an inflamed breast, once infection is excluded, IBC should always be kept in mind.
2. Features suggestive of IBC include the absence of fever, rapidly progressive symptoms,
generalized involvement of the breast and palpable non-tender axillary lymphadenopathy.
3. While IBC is a clinical diagnosis, histopathological confirmation is essential, and can be
performed via a core biopsy, or a skin punch biopsy.
4. Most units employ trimodal cancer therapy in the management of these patients.
References
1. ANDERSON W. F.. Inflammatory Breast Carcinoma and Noninflammatory Locally
Advanced Breast Carcinoma: Distinct Clinicopathologic Entities?. Journal of Clinical
Oncology [online] 2003 May, 21(12):2254-2259 [viewed 03 May 2015] Available from:
doi:10.1200/JCO.2003.07.082
2. ANDERSON WF, SCHAIRER C, CHEN BE, HANCE KW, LEVINE PH. Epidemiology of
inflammatory breast cancer (IBC). Breast Dis [online] 2005-2006:9-23 [viewed 02 May
2015] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16735783
3. BONEV V, EVANGELISTA M, CHEN JH, SU MY, LANE K, MEHTA R, BUTLER J, HSIANG D.
Long-term follow-up of breast-conserving therapy in patients with inflammatory breast
cancer treated with neoadjuvant chemotherapy. Am Surg [online] 2014 Oct, 80(10):940-
3 [viewed 02 May 2015] Available from:
4. CHIA S., SWAIN S. M., BYRD D. R., MANKOFF D. A.. Locally Advanced and Inflammatory
Breast Cancer. Journal of Clinical Oncology [online] 2008 February, 26(5):786-790
[viewed 04 May 2015] Available from: doi:10.1200/JCO.2008.15.0243
5. CRISTOFANILLI M, BUZDAR AU, HORTOBáGYI GN. Update on the management of
inflammatory breast cancer. Oncologist [online] 2003, 8(2):141-8 [viewed 01 May 2015]
Available from: http://www.ncbi.nlm.nih.gov/pubmed/12697939
6. DAWOOD S., MERAJVER S. D., VIENS P., VERMEULEN P. B., SWAIN S. M., BUCHHOLZ T. A.,
DIRIX L. Y., LEVINE P. H., LUCCI A., KRISHNAMURTHY S., ROBERTSON F. M., WOODWARD
W. A., YANG W. T., UENO N. T., CRISTOFANILLI M.. International expert panel on
inflammatory breast cancer: consensus statement for standardized diagnosis and
treatment. Annals of Oncology [online] December, 22(3):515-523 [viewed 03 May 2015]
Available from: doi:10.1093/annonc/mdq345
7. GONZALEZ-ANGULO AM, HENNESSY BT, BROGLIO K, MERIC-BERNSTAM F,
CRISTOFANILLI M, GIORDANO SH, BUCHHOLZ TA, SAHIN A, SINGLETARY SE, BUZDAR
AU, HORTOBáGYI GN. Trends for inflammatory breast cancer: is survival improving?
Oncologist [online] 2007 Aug, 12(8):904-12 [viewed 04 May 2015] Available from:
doi:10.1634/theoncologist.12-8-904
8. GüNHAN-BILGEN I, USTüN EE, MEMIş A. Inflammatory breast carcinoma:
mammographic, ultrasonographic, clinical, and pathologic findings in 142 cases.
Radiology [online] 2002 Jun, 223(3):829-38 [viewed 04 May 2015] Available from:
doi:10.1148/radiol.2233010198
9. MOLCKOVSKY A, FITZGERALD B, FREEDMAN O, HEISEY R, CLEMONS M. Approach to
inflammatory breast cancer Can Fam Physician [online] 2009/01/01 00:00, 55(1):25-31
[viewed 04 May 2015] Available from:
10. ROBERTSON FREDIKA M., BONDY MELISSA, YANG WEI, YAMAUCHI HIDEKO, WIGGINS
SHANNON, KAMRUDIN SAMIRA, KRISHNAMURTHY SAVITRI, LE-PETROSS HUONG,
BIDAUT LUC, PLAYER AUDREY N., BARSKY SANFORD H., WOODWARD WENDY A.,
BUCHHOLZ THOMAS, LUCCI ANTHONY, UENO NAOTO, CRISTOFANILLI MASSIMO.
Inflammatory Breast Cancer: The Disease, the Biology, the Treatment. CA: A Cancer
Journal for Clinicians [online] December, 60(6):351-375 [viewed 04 May 2015] Available
from: doi:10.3322/caac.20082
11. THERIAULT RL, CARLSON RW, ALLRED C, ANDERSON BO, BURSTEIN HJ, EDGE SB,
FARRAR WB, FORERO A, GIORDANO SH, GOLDSTEIN LJ, GRADISHAR WJ, HAYES DF,
HUDIS CA, ISAKOFF SJ, LJUNG BM, MANKOFF DA, MARCOM PK, MAYER IA, MCCORMICK
B, PIERCE LJ, REED EC, SCHWARTZBERG LS, SMITH ML, SOLIMAN H, SOMLO G, WARD
JH, WOLFF AC, ZELLARS R, SHEAD DA, KUMAR R, NATIONAL COMPREHENSIVE CANCER
NETWORK. Breast cancer, version 3.2013: featured updates to the NCCN guidelines. J
Natl Compr Canc Netw [online] 2013 Jul, 11(7):753-60; quiz 761 [viewed 04 May 2015]
Available from: http://www.ncbi.nlm.nih.gov/pubmed/23847214
12. WALSHE JM, SWAIN SM. Clinical aspects of inflammatory breast cancer. Breast Dis
[online] 2005-2006:35-44 [viewed 03 May 2015] Available from:
13. WANG LIJUN, WANG DENGBIN, FEI XIAOCHUN, RUAN MEI, CHAI WEIMIN, XU LIN, LI
XIAOXIAO, HOFFMANN ANDREAS-CLAUDIUS. A Rim-Enhanced Mass with Central Cystic
Changes on MR Imaging: How to Distinguish Breast Cancer from Inflammatory Breast
Diseases?. PLoS ONE [online] 2014 March [viewed 03 May 2015] Available from:
doi:10.1371/journal.pone.0090355
PLAY DISCUSSION
Back "
Itchy
Gastrointestinal System
10
1 View Clinicals
A 27 year old primiparous lady presents at 29 weeks of gestation with generalized pruritus
for one week. The pruritus is most prominent on the palms and soles and is worse at night.
Her pregnancy has been otherwise uncomplicated. Her medical history is unremarkable for
dermatological diseases and allergic conditions.
Her full blood count, renal functions and clotting profile are normal. Her urine tests negative
for proteins.
2 Investigate
Liver function tests
ALT 48 IU/L (normal 0-35)
I AST 56 IU/L (normal 0-30)

ALP 354 IU/L (normal 35-135)
GGT: 24 IU/L (normal 0-38)
Total bilirubin: 1.8 mg/dL (normal 0.1-1.2)
Conjugated bilirubin: 1.2 mg/dL
Bile acids: 14 micromol/L (normal <11)
me
Autoimmune screen
ANA: negative
Anti-smooth muscle antibodies: absent
Anti-mitochondrial antibodies: absent
Hepatitis Serology
HBsAg: negative
IgM anti HBc: negative
IgM anti-HCV: negative
Hep E antibody: negative
Liver biopsy Order
3 Manage
Ursodeoxycholic acid !
Vitamin K !
Emergency delivery
N-acetyl-cysteine
! Analysis
Liver function tests Ordered !

Autoimmune screen Ordered !
Hepatitis Serology Ordered !
Liver biopsy Not ordered !
Ursodeoxycholic acid Ordered !

Vitamin K Ordered !
Emergency delivery Not ordered !
N-acetyl-cysteine Not ordered !

Back !
Itchy
Gastrointestinal System

Pruritus may be a manifestation of a local dermatological condition - or a clue towards
underlying systemic disease. Pregnancy adds an additional dimension of complexity, as
there are several conditions unique to this time period.
Local dermatogical conditions related to pregnancy include pemphigoid gestationis, pruritic

urticarial papules and plaques of pregnancy. Those unrelated to pregnancy include xerotic
eczema, atopic and contact dermatitis and scabies.
The main systemic causes related to pregnancy are acute fatty liver of pregnancy,
intrahepatic cholestasis of pregnancy and HELLP syndrome. Important systemic conditions
unrelated to pregnancy include liver disorders (such as viral and autoimmune hepatitis) and
allergic reactions.
The unremarkable physical examination in this patient excludes local causes.
While the absence of jaundice does not rule out viral or autoimmune hepatitis, the lack of
associated symptoms such as fatigue, abdominal discomfort, nausea and anorexia makes
these etiologies unlikely.
Acute fatty liver of pregnancy (AFLP) is also unlikely, as these patients are almost always
icteric, and far more ill. Features of liver failure are o!en present.
HELLP syndrome is a severe form of preeclampsia. In this patient, the normal blood
pressure and absence of urinary proteins makes this diagnosis clinically less likely.
so
Intrahepatic cholestasis of pregnancy (ICP) is mainly characterized by generalized pruritus
which is most prominent on the palms and soles. It is a diagnosis of exclusion.
Her liver function tests demonstrate mild conjugated hyperbilirubinemia with normal
gamma-glutamyl transpeptidase levels. This pattern of findings is suggestive of cholestasis
(note that alkaline phosphatase levels may be elevated in pregnancy due to the presence of
the placental isoenzyme).
In addition, the elevated serum bile acid levels favor the diagnosis of ICP.
Her liver transaminases are only minimally elevated, while her clotting profile, full blood
count and renal functions are normal. These results exclude HELLP syndrome and AFLP.
Note that the liver transaminases are typically elevated into the thousands of units in acute
viral hepatitis. In addition, serology excludes chronic viral hepatitis, while her autoimmune
screen is unremarkable.
Thus, by exclusion, ICP is indeed the diagnosis. Note that a liver biopsy is not required for
diagnosis of ICP.
Her management should include ursodeoxycholic acid for symptomatic relief of pruritus.
and oral vitamin K (as there may be malabsorption of fat soluble vitamins, due to disruption
of the enterohepatic circulation of bile acids).
Emergency delivery is not indicated in this patient, while there is no indication for N-Acetyl-
Cysteine therapy.
Discussion
Intrahepatic cholestasis of pregnancy (ICP) - which is also known as "Obstetric Cholestasis",
is a liver disease specific to pregnancy. The incidence varies throughout the world, occurring
in only 0.01% of pregnancies in the United States, but in between 5% to 15% of pregnancies
in Chile and Bolivia.
The etiology is believed to be multifactorial with genetic, hormonal and environmental

factors playing significant roles. Women with multiple pregnancies, and/or a family history
or a personal history of ICP are at increased risk of developing the condition.
The disease typically manifests itself in the second or third trimester and completely
resolves a!er delivery. It is characterized by generalized pruritus which is most pronounced
in palms and soles and is worse at night. Skin lesions are absent except for excoriations
resulting from scratching.
Jaundice is uncommon, but may develop 1 to 4 weeks a!er the onset of pruritus. Subclinical
steatorrhea may also occur with resultant fat and fat soluble vitamin malabsorption
(especially vitamin K).
The most sensitive biochemical abnormality is elevation of the serum bile acid level, which
o!en reaches 10 to 100 times the normal values (although this is not a universal finding). In
addition, this investigation may not be freely available in certain centers and is not essential
to confirm the diagnosis.
Serum transaminases may increase 2 to 10 fold - reaching even 1000 IU/L in some patients.
Gamma glutamyl transferase is usually normal or mildly elevated, while ALP may also be
elevated - although interpretation is di"icult due to the elevation of the placental isoenzyme
during pregnancy.
The management is aimed at alleviating maternal symptoms and improving fetal outcome.
Ursodeoxycholic acid provides strong symptomatic benefit and has the additional
advantage of improving liver functions. Evidence suggests that UDCA acts by improving the
impaired hepatocellular secretion of bile; it also restores the impaired bile acid transport
across the trophoblast.
Topical emollients may also provide slight relief of the pruritus.
Daily supplementation of Vitamin K is also important. This will help prevent intra and
postpartum hemorrhage due to impaired clotting.
Note also that it is prudent to monitor these patients with weekly liver function tests (LFT)
and to confirm postpartum normalization of LFT.
ICP is associated with an increased risk for intrauterine death, as well as premature delivery,
and meconium staining of the amniotic fluid.
While the pathogenesis of the fetal complications is still poorly understood, a role for bile
acids or toxic metabolites of bile acids has been suggested. Autopsies of the stillborns show
signs of acute anoxia with serosal and pulmonary petechial bleeding without intrauterine
growth restriction.
The majority of intrauterine deaths in singleton pregnancies occur a!er 37 weeks of

gestation - thus a discussion should take place with the patient, regarding induction of
labour a!er this time.
The increased risk of maternal and perinatal morbidity from early intervention should be
contrasted with the inability to predict stillbirth if the pregnancy continues (especially in
patients with severe biochemical abnormalities). The ultimate decision on when or whether
to intervene should be taken a!er careful counseling.
The maternal outcome is almost universally favorable, with symptoms typically resolving
within a few days following delivery.
These patients do not develop long term hepatic sequelae, although ICP may recur in 60%
to 70% of subsequent pregnancies. Symptoms may recur with estrogen containing oral
contraceptive pills (OCP) and menstruation - therefore OCPs are best avoided in these
patients.
Take home messages

1. ICP is a diagnosis of exclusion.
2. Elevated serum bile acids are the most sensitive biochemical abnormality for ICP.
3. The important adverse outcomes include intrauterine death, premature delivery and
meconium staining.
4. Delivery a!er 37 weeks of gestation should be discussed with the mother.
5. Maternal vitamin K supplementation should not be neglected.
References
1. BMJ: Obstetric cholestasis (2002)
2. RCOG green-top guideline No 43: Obstetric cholestasis (2011)
3. Orphanet journal of rare diseases: intrahepatic cholestasis of pregnancy (2007)
4. AFP: liver disease in pregnancy (1999)
5. Archives of Dermatology : The Importance of Serum Bile Acid Level Analysis and
Treatment With Ursodeoxycholic Acid in Intrahepatic Cholestasis of Pregnancy (2007)
PLAY DISCUSSION
Doc Intrahepatic caseD
Cholestasis of
pregnancy ICP
Dx lo micromol Icp
1 Blood test
tests of bile
2 L FT A liver enzymes
bile ducts
3 Ultrasound of
Toc
1 Ursodeoxycholic acid
2 Vitamin K
11/2/2019 Isolated Fallopian Tube Torsion - Prognosis: Your Diagnosis | Medical Joyworks
Isolated Fallopian Tube Torsion

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A 23 year old woman presents with intermittent pain in the left lower abdomen for 3 days.
The pain was dull at rst, but became sharp and colicky last night, with radiation to the left
thigh and associated nausea and vomiting.
Her medical, surgical and family histories are unremarkable. She is sexually active and is on
combined oral contraceptive pills. Her last withdrawal bleed was 21 days ago.
She does not smoke, only drinks socially, and denies recreational drug abuse.
https://www.medicaljoyworks.com/prognosis-your-diagnosis/catalog/Obstetrics-Gynecology/Isolated-Fallopian-Tube-Torsion/play 1/3
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Legendairy Milk
WBC: 11,000/mm3 (4,000 - 11,000)

N: 57% L: 23%
Hb: 12.8 g/dL (12.1- 15.1)
Hct: 40% (36.1 - 44.3)
Platelets: 158,000/mm3 (150,000 - 400,000)
Urine hCG Test Ordered
The urine hCG test is negative
Ultrasound Abdomen + Pelvis Ordered
There is a 5.9 × 3.7 cm cystic mass in the left ovary with a ne reticular appearance. The left
fallopian tube is dilated and the whirlpool sign is noted in the proximal tube. Doppler
owmetry shows absence of ow along the tubal wall.
The uterus is empty, and the right ovary and adnexum appear normal. A small amount of
uid is seen in the pouch of Douglas.
CT Abdomen + Pelvis Ordered
There is a simple cystic mass measuring 6.0 × 3.8 cm in the left ovary; the cystic content is
highly attenuated. The left fallopian tube is thickened and dilated, with a diameter of 12
mm, and appears to be twisted. The uterus is deviated towards the left.
A small amount of intraperitoneal uid is present.

Urgent Laparoscopy
Aspirate Ovarian Cyst
Doxycycline
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Doc Ovarian torsion Casey
secondary to ovarian
cyst
Dx 1 Pelvic exam
tests checkhormones
2 Blood test FSH LH CA125
3 U S of pelvis
4 Histology ftp.in YYyEtitis
Toc 1 Laparoscopic oophoropexy

2 Surgical removal of cyst be is
3 If the above 2
fails
do a
salpingo oophorectomy
LHS

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Gynaecology osce

Endometriosis is a condition in which tissue similar to that which lines

Obstetric anaesthesia and analgesia

Benign ovarian cyst

● Active phase. The cervix is 4 to 10 cm dilated.

● Active phase. The mother feels a need to push, or contract the

abdominal muscles in time with uterine contractions.

Amniotic fluid embolism

4.)Placenta percreta occurs when the placenta grows completely

Symptoms for Increta and Percreta:

Amniotic fluid embolism treatment

There are 3 types of regional anesthesia: spinal, epidural and combined

A breech presentation is when the fetus presents buttocks or feet first

First trimester screening is a prenatal test that offers early information

Second trimester prenatal screening

Screening is usually done by taking a sample of the mother's blood

○ Other chromosomal abnormalities

○ Defects in the abdominal wall of the fetus

A fetal ultrasound (sonogram) is an imaging technique that uses sound

Müllerian agenesis is caused by embryologic underdevelopment of the

Hyperprolactinemia is a condition in which a person has higher-than-

amount of thyroid hormone, is a common disorder, particularly in

women of childbearing age.

Anti-D immunoglobulin is administered routinely during the third

In D alloimmunization, an RhD-negative pregnant woman who is

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Acute Appendicitis in Pregnancy exam FI

Step 1: View clinicals meantime

Symphysial fundal height

could indicate possible

Step 2: Order all relevant investigations

Ultrasound Abdomen Ordered

MRI Abdomen & Pelvis Ordered

Diagnostic Laparoscopy Not ordered

GC + CT NAAT Not ordered

Step 3: Select appropriate management

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McBurney's point palpate

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Step 2: Order all relevant investigations

Early Morning Total Testosterone Ordered

Early Morning Total Testosterone: 440 ng/dL (8-60)

Endocrine Pro le Ordered

Total Testosterone: 420 ng/dL (8-60)

Percutaneous Fine Needle Aspiration Biopsy Ordered

Step 3: Select appropriate management

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