PBLs Flashcards
Case 6:
36 yo African Carribean Fabd swelling x 10 months
* What were positives and negatives?
* Menses?
* Pregnancy hx?
- (+): nausea w/ large food intake, urinary frequency
- (-): abd pain, dysuria, or hematuria, bowel movements – normal
- Menses: regular, heavy w/ clots + flooding on days 2-3; never tx’d
- Hx: partner x 7 years, no contraception used, never pregnant but desires to conceive
Case 6: Abdominal Swelling
36 yo African Carribean F abd swelling x 10 months
* What did the PE show?
* Bimanual exam?
- PE: distended abd w/ smooth, non-tender, mobile, firm palpable mass extends from symphysis pubis to midway between her umbilicus + xiphisternum. Though non-fluctuant, not able to palpate below the mass
- Bimanual exam: non-tender firm mass in pelvis
Case 6
The abdominal swelling is measuring to what gestation size?
A palpable mass extending from the symphysis pubis to midway between the umbilicus + xiphisternum suggests a significant uterine enlargement, which could be associated with a pregnancy of around 32 weeks gestation.
Case 6
What were the lab results for the patient?
Also showed iron def anemia
Case 6
What does this show?
Given the appearance of a well-defined round structure within the uterus, it could potentially represent a uterine fibroid, a common benign tumor of the uterus. Fibroids often appear as hypoechoic (darker) or heterogeneous areas on ultrasound and can vary in size.
Case 6
What does this show?
A large, well-defined mass in the pelvis. Given its size, location, and characteristics, this mass represents a large uterine fibroid (leiomyoma). Fibroids often appear as well-circumscribed, homogeneous, and hypo- or isointense on T1-weighted MRI and may have heterogeneous intensity on T2-weighted images, especially if they have areas of degeneration.
Case 6
Considerations Based on Race/Ethnicity:
* higher prevalence in who?
* What happens with eariler onset?
* Severe sxs?
* Increased surgical treatment?
Case 6
Considerations Based on Race/Ethnicity:
* Post-Surgical Pain & Anemia:
* Complications After Myomectomy:
* Higher Blood Transfusion Rates:
* Recurrence?
Case 6
Any further testing and results?
Endometrial Biopsy: rule out underlying endometrial pathology given pt’s hx(heavy menstrual bleeding, infertility, age)
* results: pending.
Fertility Testing: assess reproductive health, identify barriers to conception, + guide management of abdominal mass and fertility journey.
* results: pending.
Case 6
Any further testing and results? (besides endometrial biopsy, fertility testing)
Thyroid Function Tests:thyroid dysfunction can affect menstrual cycles + fertility.
* results: normal.
Hormone Profile:(FSH, LH, Estradiol, Progesterone)FSH/LH: evaluate ovarian function + menstrual cycle regulation.
* results: normal.
What is the dx of case 6 and the supporting evidence?
case 6
What is the treatment of myomectomy pre op?
Informed Consent (including risks of recurrence)
Type and Crossmatch
Potential Prophylactic Antibiotics (Cefazolin)
* ACOG does not recommend the need, though many surgeons still do
Sequential Compression Device Set-Up
Case 6
Treatment: Myomectomy Operation
* How does it work?
- Whenever possible, a low transverse abdominal incision is made.
- Linea alba is separated from its attachment to the rectus fascia up to umbilicus
- If at all possible, the uterus, and leiomyoma(s), are exteriorized for easier resection. If not, it is debulked inside the abdomen until it can more easily be exteriorized.
- Tourniquet is placed around base of lesion to minimize bleeding
- Vasopressin is injected into the leiomyoma to further reduce myometrial bleeding
- The uterus is sutured closed, along with the abdominal wall thereafter
Case 6
Treatment: Myomectomy Post-Op
* What do you need to do?
Case 6
Prognosis
* What is the prognosis for untreated leiomyomas?
Mortality/morbidity prognosis: generally good (benign)
* Small/asymptomatic fibroids often do not require treatment
* Complications that can occur include: menorrhagia, pelvic pain, reproductive complications, and urinary or bowel symptoms
Rare: transformation into a leiomyosarcoma
Fertility considerations:
* May make fertility more difficult
* Increased risk of pregnancy complications, including preterm labor, miscarriage, placenta abruption, and obstructed labor
Case 6
Prognosis
* What is the prognosis for myomectomy?
- Treatment of choice for women wishing to preserve fertility (our patient)
- Preserves uterus while improving environment for pregnancy
- Reduced miscarriage risk
- Potential for adhesions
- Risk of fibroid recurrence, especially if multiple or large prior to surgery
Case 6
What is the txt for women who do not desire fertility?
- Hysterectomy = definitive treatment
- Other treatment options exist, including oral contraceptives, hormone IUD, myolysis, and uterine artery embolization
Group 4
- What is the case?
Sarah is a 32-year-old G3P2A1 female that presents to the OB/GYN office with complaints of severe headaches, visual disturbances, and swelling in her hands and face. She reports that for the past week, she has been experiencing increasingly severe headaches that are unresponsive to over-the-counter analgesics. She also notes blurry vision and has noticed significant swelling in her hands and face, especially in the mornings. Sarah denies abdominal pain or shortness of breath. Patient is 38 weeks pregnant.
Group 4
What were the vitals?
- Blood Pressure: 160/100 mmHg (elevated)
- Heart Rate: 88 bpm
- Temperature: 98.6 F
Group 4
What was the PE?
- General Appearance: Anxious, in mild cases
- Extremities: Bilateral Edema in hands and face
- Abdomen : Soft, non-tender, no hepatomegaly or splenomegaly
- Neurological Exam: Cranial nerves intact, no focal deficits
Group 4
What were the labs?
Group 4
Why UA? What was the imaging?
Group 4
Preeclampsia
* What is it?
* What are the risk factors?
- A condition in pregnancy that causes hypertension, edema, proteinuria and other organ damage such as kidney and liver
- Risk Factors include: Hx of HTN or kidney disease, 1st pregnancy, carrying multiple fetuses, family Hx, or certain diseases such as DM, lupus, or thrombophilia
Exact cause is unknown, but thought to be due to an issue with the placenta
group 4
HELLP Syndrome
* What is it?
* Risk factors?
- A complication of pregnancy that stands for Hemolysis, Elevated Liver enzymes, Low Platelet count
- Risk Factors include: Hx of HELLP, preeclampsia or HTN, family Hx, over 35 years old
Like preeclampsia the cause is unknown but thought to be due to issues with the placenta and blood flow
Group 4
Treatment – Preeclampsia
* What is the txt?
Group 4
Follow-Up/Education
* Educate on what?
* What is the postpartum f/u?
- Educate patient on signs of worsening symptoms: severe headache, visual disturbances, chest pain, SOB
- Postpartum follow-up:BP should be monitored postpartum, some patients may develop postpartum preeclampsia or have lingering hypertension – may admit to ICU rather than L&D floor
Group 4
Follow-Up/Education
* What about future pregnacies?
* Lifestyle adjustments?
Future pregnancies
* Discuss the increased risk of recurrence in future pregnancies and the importance of early and regular prenatal care
Lifestyle adjustments
* Advise on maintaining a healthy weight, managing stress, and monitoring blood pressure regularly, especially if she has other risk factors for hypertension or cardiovascular disease
Group 5
What is the case?
Group 5
* What is the PE?
Group: 5
- What were the labs?
Group 5
What were the lab results?
Group 5
What does this show?
Ultrasound shows a 1cm x 2 cm polyp in the endometrial lining
Group 5
Endometrial biospy:
* What is the role?
* What are the limitations?
- Role: Primarily used to assess thesurrounding endometriumfor hyperplasia or malignancy, especially in patients with abnormal uterine bleeding.
- Limitations: Endometrial biopsy samples a random section of the lining, which often excludes the polyp itself. This means that while it can help detectdiffuse endometrial pathology, it typically doesnot provide specific pathology of the polyp.
Group 5
What is the best next step for diagnostics?
Best Next Step: Hysteroscopic polypectomy enablesdirect visualization and removalof the polyp, serving as both a diagnostic and therapeutic tool.
Group 5
Treatment
* What is the txt?
HYSTEROSCOPIC POLYPECTOMY
* Polypectomy under hysteroscopic guidance is the treatment of choice for most endometrial polyps.
* The goal of polypectomy in this setting is both to relieve bleeding symptoms and to detect malignancy, since symptomatic compared with asymptomatic polyps are more likely to be malignant.
* Minimally invasive- typically done out patiently
* The procedure typically takes less than an hour and doesn’t require an overnight hospital stay
* Efficacy- improvement of symptoms in 75 to 100 percent of patients
Group 5
What are the complications of HYSTEROSCOPIC POLYPECTOMY?(4)
- Infection
- More bleeding
- Injury to cervix or uterus
- pain
Group: 5
What are some other options for txt that are non invasive?
- HRT
- Progestins:Synthetic progesterone hormones that can help regulate menstrual bleeding
- Gonadotropin-releasing hormone agonists:Medications that temporarily stop menstrual periods and shrink polyps
- Hormone combined treatment:For postmenopausal women, hormone combined treatment may reduce the development of endometrial polyps
- Watch and wait: If polyps are small and asymptomatic, they may go away on their own or be managed with observation alone
Group 5
Prognosis/Follow-Up
* Benign polyps?
* Atypical or Cancerous Polyps?
- Benign Polyps: Most endometrial polyps are benign, and if they aren’t causing symptoms, they may not require treatment.
- Atypical or Cancerous Polyps: A small percentage of polyps may have precancerous or cancerous changes. For these cases, the prognosis depends on the type and extent of abnormal cells, but early detection generally leads to a positive outcome with appropriate treatment
Group 5
Post-removal Follow-up:
* Routine monitoring?
* Histopathology Follow-up?
* Recurrent Polyps?
* Long-term Outlook?
Group 5
- What is the lifesyle and self care tips?
- Track bleeding patterns to note any changes in frequency, duration, or intensity.
- Maintain a balanced diet and stay active, as general health can positively impact hormonal balance.
- Avoid smoking and manage stress, as these can affect hormone levels and overall health.
Group 5
When do you seek help?
- If you experience increased bleeding, severe pain, or new symptoms, reach out to your healthcare provider.
- Regular gynecological check-ups, including Pap smears and pelvic exams, remain essential.
Group 5
* What are endometrial polyps?
* What are they associated with?
What are they? Endometrial polyps are growths that develop on the inner lining of the uterus (endometrium). They can vary in size from small (sesame seed) to large (golf ball). Most are benign (non-cancerous), but some can be precancerous or cancerous, especially in postmenopausal women.
Causes: The exact cause is unknown, but they are often associated with:
* Increased estrogen levels (menopause, hormone therapy)
* Obesity
* Tamoxifen use (breast cancer medication)
* Lynch syndrome or Cowden syndrome (inherited conditions)
Group 5
* What are the sxs of endometrial polyps?
Many women with endometrial polyps have no symptoms.
* Abnormal uterine bleeding (heavy, irregular, or postmenopausal bleeding)
* Bleeding after intercourse
* Infertility
Group 5
* how do you dx endometrial polyps?
- Pelvic exam: May reveal a polyp protruding from the cervix
- Transvaginal ultrasound: Can visualize polyps within the uterus
- Hysteroscopy: A thin, lighted tube is inserted into the uterus to directly visualize and potentially remove polyps
Group 5
* How do you tx endo polyps?
Treatment depends on the size, number, and symptoms of the polyps, as well as the patient’s age and desire for future fertility. Options include:
* Observation: For small, asymptomatic polyps in premenopausal women
* Hormonal treatment: To shrink polyps (e.g., progestin therapy)
* Hysteroscopy with polypectomy: Surgical removal of polyps through the vagina using a hysteroscope and specialized instruments
Case 2
What is the case? What is the PHM and PE?
Group 2
What are the vital signs? What are the labs?
Group 2
What does this show?
Significant right pleural effusion with several small areas of metastasis.
group 2
What does this show?
Ascites (figure A*). Large peritoneal mass (Big arrows on B &C). Calcified fibroid (arrow heads on A & B).
group 2
What was the dx? What are the next steps?
group 2
* What is the txt plan of the ovarian cancer?
* What is the prognosis?
Group 2
What are the patient suport resources?
Group 2
Ovarian cancer clinical perals
* What is the epidemiology?
* Sxs?
* dx?
group 2
Ovarian cancer clinical perals
* txt?
* Prevention?
* What are key features?
Group 3
What is the case?
Group 3
What were the review of sxs?
Group 3
What was the medical hx? Current meds? Sex hx?
Group 3
What were the VS?
- BP → 90/60 mmHg
- HR → 110 bpm
- Temp → 98.6 F
Group 3
- What is the PE?
Group 3
What were the Pertinent Positive Test Results
group 3
What does this show?
Evidence of retained products of conception
No fetal heartbeat
Enlarged uterus
group 3
What is the assessment approach for acute uterine bleeding?
- Determine/establish hemodynamic stability
- Rule in or out pregnancy
- Identify source of bleeding
- Evaluate the volume of blood loss
- Treat underlying cause, if known
Group 3
What was group 3’s dx?
Spontaneous Abortion, Incomplete
Disseminated intravascular coagulation [defibrination syndrome]
Group 3
Spontaneous Abortion, Incomplete
* When most common?
* What are causes?
MC in first 12 weeks
Causes:
* Chromosomal defects (MC)
* Infections
* DM, Obesity, Thyroid disease, SLE
* Substance Abuse
* Medications
Group 3
Spontaneous Abortion, Incomplete
* Dx with what?
* What is incomplete?
* Sxs?
* Txt?
- Dx with transvaginal U/S
- Products of conception remain = incomplete
- Cramping, bleeding
- Treat with dilation and curettage (D&C)
Group 3
Disseminated Intravascular Coagulation (Defibrination Syndrome)
* What were the labs that led them to DIC?
- Low platelets
- Low Hgb/Hct
- Schistocytes on blood smear
- Low fibrinogen
- Normal liver enzymes
- Prolonged PT, PTT
- Increased D-dimer (baseline in pregnancy is still higher but further increased in DIC)
Group 3
DIC
* What is it?
- Disruption of hemostasis
- Widespread clotting depletes the platelets and clotting factors that are needed to control bleeding
Group 3
DIC
* What are Obstetrical DIC Causes?
Acute peripartum hemorrhage
Placental abruption
Preeclampsia/HELLP
Retained stillbirth
Septic abortion
Amniotic fluid embolism
Acute fatty liver of pregnancy
Group 3
DIC
* How is it txt?
Treat by stopping bleeding, give whole blood, broad spectrum ABX and evacuate uterus
group 3
What is the txt for the abortion?
Group 3
Prognosis
* Recover?
* Patients show have what?
* Surgical txt?
* The risk of recurrence?
- S/P blood transfusion and D&C, patients without liver dysfunction typically recover rapidly
- Patient should have a psych evaluation s/t spontaneous abortion
- Surgical treatment should not adversely affect patient’s fertility
- The risk of recurrence in subsequent pregnancies is unknown and depends on the underlying cause
Group 3
What is the patient education?
What was group 1’s case?
Group 1
What was the PMH?
Group 1
What was the ROS and PE?
Group 1
What was the uterine height?
On exam, her expected gestational age is about 16 weeks based on uterine height. This is significantly further along than the expected 2-4 weeks based on timing of positive pregnancy test and reported LMP.
Group 1
What are additional tests?
- Pelvic Exam: Vaginal exam showed closed cervical os with very minimal blood in vagina. Otherwise, normal vaginal exam.
- Serum beta-hCG: 100,000 mIU/mL
- Transvaginal US: No fetal heartbeat or identifiable structures
Group 1
What are the reasons for elevated hCG (urine and serum)
group 1
What does this show?
Gestational Trophoblastic Disease: snowstorm
group 1
What is the dx of group 1’s and why?
group 1
Hydatidiform Mole
* What is the patho? The two types?
group 1
Hydatidiform Mole
* Presentation?
* Dx?
* Txt?
- Presentation: Uterine bleeding, abd/pelvic pain, and uterine mismatch
- May present with new onset HTN (could be masked by current metoprolol use)
- Dx work up: Serum beta-hCG (high normal- millions), US (cluster of grapes/snowstorm appearance), Post termination histology
- Treatment: Evacuation and sharp curettage of uterine cavity
Hydatidiform Mole
* monitoring?
Monitoring: CXR (r/o pulmonary metastasis),
Serial beta-hCG (expected normal w/in 12-16 weeks post evacuation)
Additional chemotherapeutic regimen if hCG rises/plateaus: Methotrexate or Actinomycin D
Group one
- What are some additional testing/considerations?
Group 1
What is the patient education? Prognosis?
Group 1
Hydatidiform moles
* What are the types?
group 1
Hydatidiform moles
* What are the sxs?
* BP?
* PE?
* Labs?
* Imaging?
Group 1
- What is the management?
