ENDOMETRIOSIS W/ENDOMETRIOMA

29-year-old G0 woman presents due to painful menses. Her cycles are

regular every 28 days, of 4-5 day duration, but periods are painful,
despite the use of NSAIDs. On bimanual exam, uterus is small in size,
non-tender, and cervix mobile. Ultrasound shows a 2 cm right ovarian
cyst.
o Definition: Chronic inflammatory condition defined by
endometrial stroma and glands found outside of the uterine
cavity
o Presentation: Frequently as chronic pelvic pain and/or subfertility
o Dx: Clinical suspicion is sufficient to treat Dx only confirmed by
visualization (laparoscopy)
o Tx: NSAIDs, combined oral contraceptive pills, GnRH agonists,
progestin-containing compounds, danazol (or related androgens),
and surgical destruction of lesions
UTERINE LEIOMYOMAS
A 50-year-old G2P2 woman has a history of menorrhagia, pelvic pain,
dyspareunia, dysmenorrhea, and occasional spotting between periods.
Uterus is palpable on bimanual exam, with nodularity. Ultrasound
shows multiple fibroids. Open laparoscopy reveals five fibroids,
varying in size from 3cm to 12 cm.

Most common benign uterine tumor.

Presentation: Mostly asymptomatic; however, can present with

excessive uterine bleeding, symptoms secondary to pressure on
bladder and rectum, and, less often, distortion of the uterine
cavity, leading to miscarriage or infertility.

Presentation: enlarged irregular uterus may be found on

examination and the woman may be anemic because of
menorrhagia.

Dx: Pelvic ultrasound usually shows well-circumscribed uterine

tumors.

Tx: No treatment required if asymptomatic, but follow-up should

be scheduled annually.

Tx: If symptomatic, definitive treatment is surgical, including

hysterectomy when fertility is not desired, and myomectomy to
preserve fertility.

Tx: Nonsurgical treatments include uterine artery embolization,

gonadotropin-releasing hormone agonists, or symptomatic
management with nonsteroidal anti-inflammatory drugs
(NSAIDs).

VULVAR VAGINITIS 64-year-old G2P2 woman presents to clinic for evaluation of itching,
and dyspareunia. PE reveals foul odorous, mucousy, and white-toyellowis discharge. Vagina and cervix are poorly visualized, d/t
dischargeNo masses are noted on bimanual exam. No LAD noted. Pap
smear performed: positive for cervical cancer.

Bacterial vaginosis continues to be a leading cause of vaginitis;

other common infectious causes include trichomoniasis and
candidiasis, although noninfectious causes are also possible.

Affects all age groups of women, particularly during their

reproductive years. Black women are most commonly affected.

Common symptoms include discharge, pruritus, and

dyspareunia.

It is recommended to screen for STDs in all patients with

infective vaginitis.

Sexual partners of patients with Trichomonas vaginalis should be

treated and offered screening for other STDs.

Gonorrhea - Pelvic or lower abdominal pain and fever may be present if

ascending infection.
Chlamydia - Many are asymptomatic; intermenstrual bleeding, cervicitis, and
abdominal pain may be differentiating.
Cervicitis -

Intermenstrual bleeding; friable cervix on physical examination;

genital warts may be present if caused by HPV.

Lichen planus - Pruritus, intense vulvodynia, and dyspareunia are common

symptoms. Differentiating signs may include presence of
violaceous, flat-topped papules or plaques. These lesions may
be present elsewhere on the body (e.g., flexor wrists and
ankles).

Cervical cancer - Vaginal discharge may be physiologic, and is typically

odorous, mucousy, and white-to-yellowish. Papanicolaou smear:
positive for cervical cancer. CT of abdomen or pelvis with oral/IV
contrast: demonstrates malignancy. Vaginal wall biopsy:
features of acute and chronic desquamative inflammation.

ECTOPIC PREGNANCY / Salpingectomy-Oopherectomy

42F G3P3 s/p Essure coil placement, x4 years, s/p pregnancy x3
months for retrieval of Essure coil and tubal ligation. Patient had
Essure coils implanted in 2012 to prevent pregnancy was diagnosed
as pregnant 6 months later. Fetus delivered at term, patient comes to
OR for retrieval of coil and documentation of status of tubes, with f/u
b/l tubal ligation.

Typically presents 6-8 weeks after LMP, but may present later.

Risk factors: prior ectopic pregnancy, tubal surgery,

genital/pelvic infections, smoking, or IUD usage.

Presentation: pain, vaginal bleeding, and amenorrhea.

Hemodynamic instability and cervical motion tenderness may
indicate rupture or imminent rupture.

Diagnosis: If the patient is hemodynamically stable, transvaginal

ultrasound is the initial test of choice.

Treatment: expectant, medical (methotrexate), or surgical

(salpingectomy or salpingostomy).

Complications: rupture may present as shock d/t blood loss and

with unusual patterns of referred pain from intraperitoneal blood.

SEPTIC SHOCK 2/2 UTI/RENAL STONES during pregnancy

44 F G5P3013 presents at 22 weeks with back/flank pain and
contractions q3 minutes. Pt has a history of UTI and renal stones (for
which she states she required surgery though there are no visible
scars). Burning sensation on urination. She was on a 3-day course of
antibiotics about a month ago for UTI (cant remember what she was
given). Fetal movement is evident and regular. She experienced postcoital bleeding last week, and admits to a vaginal discharge this
morning of pink/yellow mucous. Denies N/V/D, denies hematuria. Last
oral intake 2 hours previous presentation.

PREMATURE RUPTURE OF MEMBRANE

29-year-old G1P0 woman at 31 weeks gestation presents with watery
discharge from the vagina commencing several hours ago. Her
prenatal course has been uncomplicated and she takes prenatal
vitamins and iron. She denies substance abuse, smoking or alcohol
use. On examination, her blood pressure is 110/70; pulse 84;
temperature 98.6F (37.0C).
Definition: complication of pregnancy caused by bacterial infection of
the fetal amnion and chorion membranes.

Maternal fever (intrapartum temperature >100.4F or >37.8C):

Most frequently observed sign
Significant maternal tachycardia (>120 beats/min)
Fetal tachycardia (>160-180 beats/min)
Purulent or foul-smelling amniotic fluid or vaginal discharge
Uterine tenderness
Maternal leukocytosis (total blood leukocyte count >15,00018,000 cells/L)

PRURITIS INTRAHEPATIC CHOLESTASIS OF PREGNANCY

An 18-year-old G1P0 woman presents at 32 weeks for a routine visit.
She complains of intense itching for the past two weeks and cannot
stop scratching her arms, legs, and soles of her feet. She has tried over
the counter lotions and antihistamines with no relief. She also states
that her family noticed she is slightly yellow. Her vital signs are normal
and there are scattered excoriations over her arms and legs.

occurs in the second or third trimester;

characteristically starts in the soles of the feet and palms of the
hands and progresses to the trunk and face
often worse at night
Steatorrhea and vitamin K deficiency may also occur due to fat
malabsorption; postpartum hemorrhage may ensue
Dx: total serum bile acid (BA) levels greater than 10 micromol/L
chenodeoxycholic acid level is mildly increased, leading to
elevation in the cholic/chenodeoxycholic acid level ratio
elevation of aminotransferases associated with ICP varies from a
mild increase to a 10- to 25-fold increase

HYPERTENSION IN PREGNANCY (preeclampsia)

27-year-old G1P0 woman at 34 weeks gestation presents for follow-up

with increased swelling in her face and hands over the last two days.
Blood pressure is 145/99. A 24-hour urine sample for protein dipstick is
2+. BMI is 27. Blood pressure measurement two days ago was 139/90.
Preeclampsia is defined as:
(1)SBP greater than or equal to 140 mm Hg or a DBP greater than or
equal to 90 mm Hg or higher, on two occasions at least 4 hours
apart in a previously normotensive patient
(2)an SBP greater than or equal to 160 mm Hg or a DBP greater than
or equal to 110 mm Hg or higher
Preeclampsia w/severe feature: includes end-organ damage (renal,
cardiac, hepatic, etc)

Magnesium
b-blockers
CCBs
Hydralazine (nitrates)

GESTATIONAL TROPHOBLASTIC NEOPLASIA MOLAR PREGNANCY

40-year-old G0 previously healthy woman presents to the clinic with
painless vaginal bleeding. Her last menstrual period was 16 weeks ago.
On physical exam, her vital signs are: temperature 98.6F (37.0C);
heart rate 120 beats/minute; and blood pressure 140/90. Abdominal
and pelvic examination confirms a 20-week sized uterus with a small
amount of blood in the vagina. Beta-hCG is 68,000 mIU/mL.

Dx: snowstorm pattern on U/S

Dx: elevated bHCG levels (beyond gestational age based LMP)
CXR to r/o metastasis (metastasis to lungs considered stage 3,
not 4)
Tx: suction curettage
conception possible 6mo post normalization of bHCG