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