CASE 2

Case Report:
A 27 year old woman whose last child was delivered 2 years ago, presented to Primary Care Center
on the 4th of January 2006 with a complaint of heavy prolonged menstruation. Her last normal
menstrual period was on the 7th of November 2005. Her menstrual cycle had always been regular with
normal flow. The current menstrual flow started on the 7 th of December and prolonged until the date of
first consultation at the clinic. On further questioning, she admitted that she had initially taken
treatment from another clinic to increase flow of her menstruation when she experienced scanty flow
during the first three days of this cycle. Upon treatment her menstruation became heavy and
prolonged and hence she sought a second opinion. There were no other complaints and the patient
denied any pain or discomfort in the abdomen

History:
She has been married for nine years and had three spontaneous vaginal deliveries. She was on
combined oral contraceptive pills started a year ago and claimed to be compliant with medication.
There was no history of over-the-counter or prescribed medication taken during the last menstrual
cycle. There were no significant past medical, surgical or gynaecological problems.

Examinations:
On examination she appeared comfortable and there were no signs of anaemia. Her blood pressure
was 125/70 mmHg with a pulse rate of 85/min. Abdominal examination revealed mild tenderness over
the lower abdomen. Vaginal examination excluded local causes of vaginal bleeding. On
digital examination there was tenderness at the posterior fornix. Urine pregnancy test was positive.
This was complemented by an empty uterine cavity with the presence fluid in the pouch of Douglas.
Haemoglobin count was 12.3 x 103 g/L and total white cell count was 7.5 x 109 g/L.

The possibility of ectopic pregnancy was explained to her and she was transported immediately to the
nearby hospital as she could collapse as a result of haemoperitoneum. The patient underwent
diagnostic laparoscopy the same evening. There was haemoperitonium and a leaking left tubal
pregnancy at the ampullary region. Both ovaries and the right tube were normal. Left salphingectomy
and peritoneal lavage was done laparoscopically and patient was discharged well the following
evening.
CASE 1

Bella is a 31 year old woman who came to see a doctor because she and her husband have been
trying to get pregnant, but have not been successful. She has been so afraid that she will never have
kids. Her husband has another child from a previous relationship, so she worried that there is
something wrong with her. she had been off birth control and trying for about two years. Bellas
periods have always been irregular since the very beginning. She does get her periods, but perhaps
once every one to three months; and during a time when she gained 10 pounds, she went as long as
six months without a period.

She is about five feet tall and 20 pounds overweight, and she carries most of her weight in the mid
section. She admits that she has a tough time losing weight, no matter how hard she tries. She
suffers from a mild case of acne on her face and upper back. She has a little bit of hair growth on her
upper lip, chin, stomach, and feet. The back of her neck has a thickened, dark brown, leather-like
quality to it. That is referred to as Acanthosis Nigracans, and is often a sign of pre-diabetes
or diabetes.

Laboratory Examination

Testosterone level : Slightly above normal

 Fasting blood sugar: 126 mg/dL Elevated (Normal: 70-100 mg/dL)
Thyroid Panel: Normal

Ultrasound Result

CASE 3

A dead fetus of more than four months gestation brought from Department of Obstetrics and
Gynaecology to Anatomy Department Gandhi Hospita.

External examination, radiological examination and dissection were done and findings were noted.
External Examination: Normal upper limbs, single lower limb, omphalocele, imperforate anus,
external genitals absent, single umbilical artery in umbilical cord., rudimentary tail. Radiological
Findings: Single fused lower limb showing intermingled bones with slight gap in between them, no
sacrum, and no pelvis. Vertebral column, ribs, skull bones and upper limb bones were normal.

Dissection: On dissection, we found a single umbilical artery that was the continuation of the
abdominal aorta. Part of mid gut loop was outside the abdominal cavity in the covering of umbilical
cord, Other findings were colonic atresia, absence of kidneys, ureters, and urinary bladder and lungs
were hypoplastic. Gonads were normaly present in iliac fossae.
CASE 4

9-hour-old female conjoined twins with one torso and two heads were brought into the sick babies
unit (SBU) by a 25-year-old Nigerian mother of the Ekoi tribe in Cross Rivers State who just had her
first delivery. She had limited antenatal care (ANC) in a primary health centre where no antenatal
ultrasonography had been carried out. The pregnancy, which was carried to term, was characterized
by regular use of an herbal enema from the onset and polyhydramnios. The delivery had been
completed vaginally at home without any obstruction to labour. The normal head presented first. Only
the normal twin cried after several minutes of stimulation. The combined weight of the conjoined twins
at the time of admission was 2.85 kg.

Clinical examination revealed two discordant heads. The normal and anencephalic heads had an
occipito-frontal circumference of 34 cm and 24 cm, respectively. There was a single thorax with two
neurologically independent upper limbs, single abdomen, one complement of genitalia and an anus as
well as two neurologically independent lower limbs.

At presentation in the SBU, the anencephalic twin was unresponsive to painful stimulus with dilated
and unreactive pupils. An orogastric tube was inserted that ended in the neck of the twin.

The normal twin remained stable for a short while but soon experienced repeated apneic attacks with
cyanosed extremities. Though prompt resuscitative measures were taken, the twin died within 9 hours
of birth from cardiopulmonary failure. As a result of their unstable condition and the short duration of
life, thorough investigation of the twins was not possible.

Post-mortem Babygram findings

 Post-mortem plain X-ray findings showed a fully developed cranium with normal facial structures
continuous with the main body. The second head was devoid of a cranium. Each cranium was
connected via a separate spine that terminated abruptly at the fifth lumber vertebrae with no evidence
of any sacral component . The ribs on the medial side of each twin were fused with each other
creating 12 instead of 24 posterior ribs, but the other ribs had not fused. Each upper limb and clavicle
appeared borne by the twin on that side. The lungs and heart were not demonstrable but the single
pelvis and lower limbs are clearly defined.

Autopsy findings
The head with normal calvaria contained a well-formed brain whereas the anencephalic head had
no forebrain. Two complements of neck organs and two vertebral columns were demonstrable. The
right trachea continued to a right-sided pair of normal lungs while the left trachea joined a pair of
collapsed and hypoplastic lungs. A single intestinal tract opened to the exterior as a well-formed anal
canal. The other abdominal and pelvic organs were not duplicated.

Two pairs of great vessels , two aortic and two superior vena cavae entered the single heart. There
were two atria, two rudimentary auricular appendages and two ventricles.