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Case OB Gyne

A 32-year-old woman with a history of amenorrhea, abdominal pain, and slight vaginal bleeding presents with a positive home pregnancy test. The likely diagnosis is ectopic pregnancy, supported by her medical history of appendectomy and pelvic inflammatory disease. Recommended investigations include transvaginal ultrasonography and quantitative beta-hCG testing, with treatment options ranging from surgical interventions to methotrexate for unruptured cases.

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Jeslin
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16 views5 pages

Case OB Gyne

A 32-year-old woman with a history of amenorrhea, abdominal pain, and slight vaginal bleeding presents with a positive home pregnancy test. The likely diagnosis is ectopic pregnancy, supported by her medical history of appendectomy and pelvic inflammatory disease. Recommended investigations include transvaginal ultrasonography and quantitative beta-hCG testing, with treatment options ranging from surgical interventions to methotrexate for unruptured cases.

Uploaded by

Jeslin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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A 32 year old woman presents with a history of 6 weeks amenorrhea, abdominal pain

and slight vaginal bleeding. She was on oral contraceptive pill since she was 28 year old but
she stopped 2 years ago since she and her husband wanted to conceive. She booked an
appointment with you as her doctor since she has been feeling dizzy. A home pregnancy test
is positive. She has previously had an appendectomy and pelvic inflammatory disease.

Each group must make a 7 minute powerpoint presentation of this case during Clinics. Each
group should submit a typewritten report containing the answers to these questions.

1. What is the likely differential diagnosis?

1. Ectopic pregnancy
rule in: amenorrhea, abdominal pain and slight vaginal bleeding, oral contraceptive
pill 2 years, GA 6 wk and have previously had an appendectomy and pelvic
inflammatory disease.
rule out: N/A
2. Normal pregnancy due to implantation bleeding
rule in: Patient present with amenorrheaa and abdominal pain
rule out : occurs about 10 to 14 days
3. H. mole
rule in: Patient present amenorrhea, vaginal bleeding, abdominal pain
rule out : occurs about 9 - 12 wks, severe vomiting
4. Threatened Abortion
rule in: Patient has vaginal bleeding, abdominal pain, occur first 20 wks
rule out : Heavy bleeding may persist for days or week, may be accompanied by
suprapubic discomfort, mild cramps, pelvic pressure, or persistent low backache.

Final Diagnosis : Ectopic pregnancy


 Ectopic pregnancy usually present between GA 6-10wk
 Classical triad: Amenorrhea, Abdominal pain, Vaginal bleeding
 Risk factor: She has previously had an appendectomy (abdominal
surgery ) and pelvic inflammatory disease, utero exposure to
diethylstilbestrol.

2. What issues in the given history support the diagnosis?


1. She presents with a history of 6 weeks amenorrhea, abdominal pain and slight
vaginal bleeding.
2. She has been feeling dizzy.
3. She has a home pregnancy test is positive.
4. She has previously had an appendectomy and pelvic inflammatory disease.
5. She was on oral contraceptive pill since she was 28 year old but she stopped 2
years ago since she and her husband wanted to conceive.
3. What additional features in the history would you seek to support a particular diagnosis?
1. History of prior ectopic pregnancy
2. History of cigarette smoking.
3. History of fallopian tube surgery.
4. History of Endometriosis.
5. History use of infertility drugs.

4. What clinical examination would you perform and why?


Ectopic pregnancy :
- Auscultation : Hypoactive bowel sounds
- Palpation : mass at right or left lower quadrant “Adnexal mass”
- V/S : Hypotension

5. What investigations would be most helpful and why?

Transvaginal ultrasonography followed by quantitative beta-hCG testing is the


optimal and most cost-effective strategy for diagnosing ectopic pregnancy

1. CBC
Decreasing of hemoglobin and hematocrit levels, Increasing of White blood cell can
be found.
2. Combined transvaginal ultrasonography and serial quantitative beta-hCG
measurements are approximately 96 % sensitive and 97 % specific for diagnosing
ectopic pregnancy.Therefore, transvaginal ultrasonography followed by quantitative
beta-hCG testing is the optimal and most cost-effective strategy for diagnosing
ectopic pregnancy
Ultrasonography
Diagnostic test of choice for Ectopic pregnancy:
• transabdominal ultrasonography
• (-) intrauterine gestational sac
• beta-hCG > 6,500 mIU per mL (6,500 IU per L)
• transvaginal ultrasonography
• (-) intrauterine gestational sac
• beta-hCG => 1,500 mIU per mL (1,500 IU per L)
Various transvaginal sonographic findings with ectopic tubal pregnancies. For
sonographic diagnosis, an ectopic mass should be seen in the adnexa separate from the ovary
and may be seen as:
(A) a yolk sac (shown here) and/or fetal pole with or without cardiac activity within
an extrauterine sac,
(B)an empty extrauterine sac with a hyperechoic ring, or
(C) an inhomogeneous adnexal mass. In this last image, color Doppler shows a classic
“ring of fire,” which reflects increased vascularity typical of ectopic pregnancies. LT OV =
left ovary; SAG LT AD = sagittal left adnexa; UT = uterus

1. Beta-HCG levels
36% sensitive and 65% specific
< 66% rise every 48 hours = Ectopic pregnancy
2. Serum progesterone
< 11ng/ml = ectopic
3. Culdocentesis ( Checks for abnormal fluid in the abdominal cavity behind the uterus)
(+) non-clotting blood = ruptured ectopic

6. What treatment options are appropriate?


Surgical
Laparoscopy vs laparotomy
 Salpingostomy
o This procedure is typically used to remove a small unruptured
pregnancy. A 10- to 15-mm linear incision is made on the
antimesenteric border of the fallopian tube over the pregnancy. The
products usually will extrude from the incision. These can be carefully
removed or flushed out using high-pressure irrigation that more
thoroughly removes the trophoblastic tissue (Al-Sunaidi, 2007).
o <2cm in the distal third of fallopian tube
o unsutured
 Salpingotomy
o <2cm in the distal third of fallopian tube
o sutured
 Salpingectomy
o Tubal resection may be used for both ruptured and unruptured ectopic
pregnancies. To minimize the rare recurrence of pregnancy in the tubal
stump, complete excision of the fallopian tube is advised. With one
laparoscopic technique, the affected fallopian tube is lifted and held
with atraumatic grasping forceps (Thompson, 2016).
 Hysterectomy
o a surgical procedure to remove the womb (uterus). You'll no longer be
able to get pregnant after the operation
o a major operation with a long recovery time and is only considered
after less invasive treatments have been tried

Medical
1.Methotrexate : Folinic acid antagonist Inhibits dihydrofolic acid reductase
Criteria for receive MTX
-AOG < 6 weeks
- Unruptured mass <3.5cm in diameter
- No Fetal Cardiac motion detected
- BHCG <10,000 mlU/mL

Group members :

1. Hinyai, Suchanard
2. lamaroon,Ratanapan
3.Jakhariya, Foram Mahesh
4.Jani, Mahek Pradeepbhai
5.Jobe, Joanna Light
6.John Rasal, Jeslin

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