SOUTHWESTERN UNIVERSITY

School of Medicine
Department of Obstetrics & Gynecology

CLINICO-PATHOLOGICAL CONFERENCE
DISCUSSANTS:

Ghimire, Deepak
Romero, Jiesta Anna Monica
Campugan, Harjarra Kate
Abraham, Leonard
MARCH 16,2016

General Data
A case of R.V.
28 years old female
G2P1011
LMP : October 30, 2013
Admitted on December 25,2013

Chief Complaints

Epigastric pain

History of Present Illness

10 days PTA

Onset of localized epigastric

pain
No other associated signs and
symptoms

History of Present Illness

7 days PTA

Persistence of epigastric pain

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

History of Present Illness

One day PTA

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

History of Present Illness

Few hours after admission

Referred to the Department of

OB & GYN
Persistent epigastric pain
Radiating to the entire abdomen
Associated with muscular-like
pain over the right shoulders

Obstetrical History

No of
Pregnancy

Year

Outcome
(AOG)

Mode of
delivery

Hospital
delivered

Indication

Remarks

G1

2011

Full Term ,
male

Cesarean
Section

VSMMC

Breech

G2

2013

Spontaneous
abortion

NO Dilatation &
curettage done

Menstrual History
12 years old x 28- 30 days cycle
x 5 days
Consumes 3 pads per day,
moderately soaked.
No dysmenorrhea.

Sexual History
Coitarche at 19 years old
4 sexual partners
Denies history of sexually
transmitted disease

Contraception History
Combined oral contraceptive
pills
2 years ago
Duration 7 months

Past Medical History

Known asthmatic since childhood
Last attack was unrecalled

No food & drug allergy

Previous Hospitalization
VSMMC , 2011
Cesarean delivery of term pregnancy in breech
presentation

Personal Social History

Non-smoker
Non-alcoholic beverage drinker.
Worked as a masseuse in a
local spa and massage unit.

Family History
Unremarkable

Physical Exam
Patient is awake, conscious ,coherent
and afebrile
Vital signs:
BP: 90/60 mmHg
HR: 86bpm
RR:1 6cpm
Temp: 36.7'C

Physical Exam
Skin: Warm, Good turgor, (+) Pallor

HEENT: Pale palpebral conjunctivae, Anicteric

sclerae
Chest & Lungs: ?
Cardiovascular : ?

Physical Exam
Abdomen:
Flat , soft , Normoactive bowel
sounds
direct & rebound tenderness
(Epigastric & Right Lower abdomen )

Speculum exam
Cervix congested
Non-foul smelling non-bloody
discharges

Bimanual Pelvic Exam

Cervix : Closed, firm, posterior with
equivocal tenderness on palpation
Uterus: Slightly tender, not
enlarged,
Adnexa: (+) tenderness at the right

Rectal Exam
Good sphincteric tone
Tender towards the right area
No palpable mass
(+) fecal material on examining
finger

Laboratory Results
CBC results
Value

Ref.

WBC

20.7 x 103/mm3

4.4 -11.0

HGB

8.4 g/dl

12.3-15.3

HCT

26.6%

35.9-44.6

PLT

252 x 103/mm3

150-450

Laboratory Results
Blood test results
Value

Ref.

SGPT

Up to 41 U/L

SGOT

13

Up to 33 U/L

Alkaline Phosphatase

62.0

Up to 32 U/L

Serum Amylase

37.0,

0-85 U/L

Serum Lipase

13.0

13-60 U/L

Serum Na

137.0

136 145 mmol/L

Serum K

3.6

3.5 5.1 mmol/L

LDH

146.0

132-228 U/L

Ultrasound of the Abdomen

Normal-sized liver with diffuse fatty changes
Normal Gallbladder, Pancreas, Spleen ,both
kidneys & Urinary Bladder
Normal-sized anteverted uterus
Adnexa not visualized (obscured by
intraperitoneal fluid)
(+) complex mass at right lower abdomen

Issues ?
What is her usual Blood
pressure?
Any new medication given by
SHH-IM ?
What are chest and
Cardiovascular findings?
What is the description of
epigastric pain ?
Is there urine Pregnancy test
done ?
Is transvaginal ultrasound (TVS)
done ?

Salient features of the case

28 Years old multigravid
8 weeks amenorrhea
10 days history of persistent epigastric pain
radiating to entire abdomen
(+) muscular like pain right shoulder
History of operative delivery & spontaneous
abortion
Multiple sexual partners
History of combined oral contraceptive use

Salient features of the case

Afebrile with blood pressure in lower

margin (90/60 mmhg)
Pallor & pale palpebral conjuctivae
Direct and rebound tenderness on
epigastric and right lower abdomen
Right adenxal tenderness
Tenderness in rectal exam

Salient features of the case

Leukocytosis of 20,000 /mm3

Moderate Anemia (Hgb 8.4 g/dl)
UTZ finding :

(+) free intraperitoneal fluid (

hemoperitoneum)
(+) complex mass at RLQ

Differential Diagnoses
Salient features

Ectopic
pregnancy

Ruptured Corpus
luteum cyst

Ovarian
tumor

Acute
Appendicitis

Appendicitis
Classically Epigastric pain is followed by Nausea,
vomiting & anorexia
Epigastric Pain then shifts to RLQ
(+) Signs of peritoneal irritation like Direct &
rebound tenderness
May have fever, mild leukocytosis and (+)
periappendiceal fluid
WBC >18,000 cells/mm3 raise the possibility of a
ruptured appendix

Appendicitis
RULE IN

RULE OUT

HISTORY &
PHYSICAL
EXAM

Common in 10-30 y.o

(+) epigastric pain
(+) RLQ pain & tenderness
May have Adnexal tenderness
May have Rectal pain

(-) Nausea (-) anorexia

Peritoneal fluid not explained
Amenorrhea not explained
Shoulder pain less defined

LABORATORY

WBC elevated >10,000/mm3

Appendiceal abscess may present
ascomplex mass
(+) periappendiceal fluid

anemia is not explained

REMAR
KS

Differential Diagnoses
Salient features

Ectopic
pregnancy

Ruptured Corpus
luteum cyst

Ovarian
tumor

Acute
Appendicitis

Ovarian Tumor
1. Serous cystadenomas

Second most commongynecologiccancer.

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

.Most frequent ovarian epithelial

tumor
age
group
.Benign: reproductive age group
.May contain serous fluid and solidtissue component
.Ascites, abdominal discomfort
.Diagnosis established by histologic
exam
.elevated serum CA-125(>90%)

Associated with low parity and infertility

Ovarian Tumor
Ovarian tumors are common

1. Mature cystic teratoma

most common neoplasm of the ovary

in reproductive
80% are benign in reproductive age
group years
contains derivatives of 3 germ layers
May arise from
(ectoderm, mesoderm & endoderm)
Mostly unilateral (15% bilateral )
Epithelium ( 70%)
Dull aching pain in lower abdomen,
heaviness
Stroma (15%)
Complication
Germ cells (10%)
Torsion (1520%)
rupture(1%)
Metastatic (5%)
CA-19-9can be used as aid in the
diagnosis
Associated with low parity and infertility

Ovarian tumor
RULE IN

RULE OUT

HISTORY &
PHYSICAL
EXAM

common in reproductive age group

May produce dull aching pain
(+) adnexal tenderness
(+)
(+) pallor / (+) anemia

(-)Family History
(+) multigravid (+) COCP
(-) palpable mass
epigastric pain not well explained
Amenorrhea uncommon
Shoulder pain not explained

LABORATORY

(+) complex mass

(+) free intraperitoneal fluid

Leukocytosis uncommon

REMARKS

Differential Diagnoses
Salient features

Ectopic
pregnancy

Ruptured Corpus
luteum cyst

Ovarian
tumor

Acute
Appendicitis

Ruptured Corpus luteum cyst

Functional cyst developing in the luteal phase of the
ovarian cycle
Regresses spontaneously in Corpus albicans when
pregnancy does not occur
Failure to regress Progesterone and estrogen secretion
Amenorrhea followed by uterine bleeding
Prone to hemorrhage and torsion
Rupture unilateral abdominal pain & features of
peritoneal hemorrhage

Ruptured Corpus luteum cyst

RULE IN

RULE OUT

REMARKS

HISTORY &
PHYSICAL
EXAM

Reproductive age (18-35)

Occurs after ovulation
(+) amenorrhea
Described cause of RLQ pain (epigastric pain )
Ruptured ( pallor, hemodynamic changes)
(+) direct & rebound tenderness
adnexal tenderness

No history of recent
exercise and sexual
intercourse
(-) sharp pain at the
lower abdomen
Amenorrhea not
followed by vaginal
bleeding

Cannot totally
rule out
but less likely
explains
amenorrhea
without
vaginal
bleeding

LABORATORY

Leukocytosis
Hematocrit may fall
complex adnexal mass in UTZ

Normal sized uterus

(indicates no Intrauterine pregnancy)

hCG-levels not given ?

Differential Diagnoses
Salient features

Ectopic
pregnancy

Ruptured Corpus
luteum cyst

Ovarian
tumor

Acute
Appendicitis

Ectopic pregnancy
Defined as implantation outside normal
uterine cavity
suspected in any women with
amenorrhea and any abdominal pain
Triad : Amenorrhea, abdominal pain,

irregular vaginal bleeding

(<50 %)

Usually have risk factors prior pelvic

Ectopic pregnancy
Fate of ectopic pregnancy depends on site of
implantation
Presents with abdominal pain (>98%)
shoulder pain & epigastric pain are rare feature
(atypical)
Signs of peritoneal irritation & cervical/adnexal
tenderness
Hemodynamic instability

Ectopic pregnancy
RULE IN

RULE OUT

HISTORY &
PHYSICAL
EXAM

Reproductive age,
Amenorrhea, abdominal pain
(+)Risk factors- multiple sexual partner, prior
pelvic surgery, Prior abortion
(+) peritoneal signs/shoulder pain
(+) right adenxal tenderness
(+)pallor, low range B.P.

Epigastric pain
is not typical
feature

LABORATORY

Leukocytosis
Low Hematocrit
UTZ
free intraperitoneal fluid
(+) complex mass at RLQ

REMARKS

Cannot
RULE OUT

Differential Diagnoses
Salient features

Ectopic
pregnancy

Ruptured corpus
luteum cyst

Ovarian tumor

Acute
Appendicitis

MOST LIKELY DIAGNOSIS

Ruptured Ectopic pregnancy

Ectopic pregnancy

DISCUSSION

Incidence
The frequency of ectopic pregnancy is 1 .
3-2 %
Majority of patients with ectopic
pregnancy are 2 1-30 years age group
Multiparous women were found to be more
prone to have ectopic pregnancy
The gestational age ranged between 4-11
weeks and the most frequent gestational

Risk factors for ectopic pregnancy

High risk

Moderate risk

Slight risk

Tubal surgery

Infertility

Previous pelvic/abdominal
surgery

Sterilization

Previous genital
infections

Cigarette smoking

Previous ectopic
pregnancy

Multiple sexual
partners

Vaginal douching

In utero exposure to
diethylstilbestrol

Early age at first

intercourse (< 18 years)

Use of IUD

Previous spontaneous
abortion or induced
abortion

Documentedtubal

Mechanism of ectopic
pregnancy

Features of Ectopic pregnancy

Acute abdominal pain (100%)
Amenorrhea (6-10 weeks)
Slight or No vaginal bleeding
Syncope, hypotension & pallor
Pelvic tenderness, Uterus enlarged &
soft
Fever is unusual

Ultrasound findings indicative of ectopic pregnancy

1. Empty uterus with a tubal ring

2. Complex adnexal mass - most
common finding
3. Moderate-to-large amount of free
fluid (70%)
4. Definite extrauterine pregnancy
(20%)
Frates MC, Brown DL, Doubilet PM, Hornstein MD. Tubal rupture in patients with ectopic pregnancy:
diagnosis with transvaginal US.Radiology. Jun 1994;191(3):769-72.[View Abstract]

Other finding in suspected

ectopic pregnancy
shoulder tip pain, syncope and shock 20%
one third of women with ectopic pregnancy
have no clinical signs
Abdominal tenderness- >9%75%.
have no symptoms
Cervical motion tenderness - 67%
palpable adnexal mass - 50%.
Weckstein LN, Boucher AR, Tucker H,et al.Accurate diagnosis of early ectopic pregnancy.
Obstet Gynecol1985;65:393397.

Predictor of ruptured ectopic

pregnancy
Severe Abdominal pain With
Rebound tenderness
Fluid in Pouch of Douglas In TVS
Low serum hemoglobin (pallor)
Doppler ultrasound can differentiate ectopic pregnnancy
from other adnexal mass

Ectopic pregnancy : common

implantation sites

Localizing ectopic pregnancy :

common sites
Site

% incidence

Fate

Ampullary
(70%)

Wide, distensible

Ruptures at 8-12 weeks (tubal abortion)

Isthmus
(12%)

Narrowest part of tube

Ruptures Early 6-8 weeks, bleeds profusely

Fimbrial end
(11%)

Part close to ovary

Rupture is rare, mainly aborts

Cornual
(2-3%)

More distensible

Detected late (14 weeks) ,

devastating hemorrhage

more distensible

May rupture early ,

Abdominal 1-2 %

Depends on site

Adnexal May go up to term

Omental may rupture < 5 weeks

Other

depends

Tubal
(95-95 % )

Ovarian

3%

<1 %

painless vaginal bleeding (cervical)

Spiegelberg criteria for diagnosis of ovarian pregnancy

Thegestational sacis located in the region of theovary.

The ectopic pregnancy is attached to the uterus by the

ovarianligament.

Ovarian tissuein the wall of the gestational sac is proved histologically.

Thetubeon the involved side is intact.

Abdominal pregnancy
The implantation sites may be
Omentum (least common)
Liver, ovaries, pouch of doughlas or
Broad ligament (most common)

Primary abdominal pregnancy

Secondary Abdominal pregnancy after tubal
rupture or tubal abortion

Studdiford's criteria for primary

abdominal pregnancy
1

Normal bilateral tubes and ovaries with no evidence of recent or

past pregnancy.

No evidence of a uteroperitoneal fistula.

The presence of pregnancy related exclusively to the peritoneal

surface, early enough to eliminate the possibility of secondary
implantation after primary tubal nidation

Features favoring abdominal

pregnancy
Predominantly epigastric pain without lower
abdominal pain
Signs of massive peritoneal bleeding in early
gestation
No vaginal bleeding
Normal sized uterus
Equivocal cervical tenderness

FINAL DIAGNOSIS

Ruptured Ectopic pregnancy

(most likely Omental)