Professional Documents
Culture Documents
OF UNKNOWN LOATION
Mrs. Wasana was a 21 years old lady who has been married for one year duration
and she came from Polonnaruwa. She complained lower abdominal pain for two
weeks duration and had sixteenth weeks of period of amenorrhea. She had had
irregular cycles since her menarche and cycle length varied from 45 days to 60
days. On examinations her BMI was29Kg/M 2 and was not pale. Her pulse
ratewas78bpm-1 and blood pressure was 110/60mmHg.There was a mild diffuse
tenderness in the lower abdomen. On bimanual examination uterus was normal
in size. However, cervical motion tenderness and adenexial tenderness were
detected, especially in the right side.
Although urine HCG strip test was positive, Ultrasound scan did not show an
intrauterine pregnancy. Even though there was a detectable amount of free fluid
in the pouch of Douglas, adenexial masses were not detected. Working diagnosis
of ectopic pregnancy was made due symptoms and presences of free fluid .The
decision was made to perform a diagnostic laparoscopy.
Patent presented with lower abdominal pain and positive Urine HCG. Initially,
there was no detectable intra uterine pregnancy and free fluid was seen in the
pouch of Douglas. Clinical features and ultra sounds evidence created the doubt
of possibility of ectopic pregnancy. Nevertheless, considering the fact that, she
was clinically stable, serial beta HCG assessment would have been a better
management option.
She had diffuse lower abdominal pain and cervical motion tenderness. In addition
to that, Initial ultra sound scan did not revealed an intra uterine pregnancy.
Furthermore, presence of free fluid created the doubt of ectopic pregnancy. As
laparoscopy is one of the popular surgical methods, which we carry out to
manage ectopic pregnancy in my unite, it was performed on this patient as well.
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What did you learn from this experience?
Ectopic pregnancy can have several clinical presentations. Provided that patient
clinically stable and criteria are fulfilled, there is a place for conservative
management with serial serum beta HCG measurements, before considering
surgical management.
This type of cases are managed as pregnancy of unknown location and serial
serum beta HCG is the management of choice, particularly if values is less than
1000iu/ml.
No
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Comments of trainee:
Assessment: mark/grade..
Date..
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REFLECTIVE PRACTICE DOCUMENTATION MANAGEMENT OF SEVERE
ENDOMETRIOSIS
Mrs. Amali Rangika , 27years old lady, who has been married for 5 years ,came
from Kaduwela, was a known patient with severe endometriosis and admitted for
laparoscopic clearance of endometriosis. She was investigated for primary sub
fertility of four years and had had premenstrual build up and out lasting
dysmenorrhea and deep dyspareunia. However, she did not complain of
menorrhagia which can be associated with endometriosis.
She had undergone laparoscopic adhesiolysis and excision of right side ovarian
endometrioma in 2010and had repeat laparoscopic adhesiolyasis and tubal
patency test, six months after previous surgery. Even though ,she had severe
endometriosis, her both tubes were patent. Following this surgery, sub fertility
was planned to manage with ovulation induction and intra uterine insemination
of sperms. However, patient defaulted treatments and presented again with
severe abdominal pain in 2013. She underwent laparoscopic evaluation after
initial evaluation and found to have, extensive adhesions due to severe
endometriosis. Complete adhesiolysis was not carried out during the procedure
due anatomical reasons and continuous combined oral contraceptive pills had
been prescribed. Repeat laparoscopic evaluation was performed after this
admission and extensive adhesiolysis with excision of left sided endometrioma
were carried out. However, both tubes were patent to dye test.
Post operative recovery was uneventful and She was discharged, after
counseling and planned to do Intra uterine insemination following ovulation
induction, even though, the best management would be invitro fertilization in
this type of cases.
Even though, with first laparoscopy correct diagnosis was made, subsequent
management was not satisfactory. patient would have been offered proper
counseling and directed to a proper management pathway of, either ovulation
induction and intra uterine insemination or in-vitro fertilization and no one
counseled her about poor reproductive outcome of this condition. Moreover
continuous combined oral contraceptive pills were started on her, though she
had reproductive wishes.
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During the last four years she had undergone 3 laparoscopic evaluations, for the
same condition but,no one attempted for counsel her regarding suppression
therapy and assisted reproductive technique such as in vitro fertilization or
adoption ,which are more suitable for this couple.
They offer the suppression therapy for endometriosis and do the assisted
reproductive method like IVF
No
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All the doctors involved in management of gyaenacological ward, should be
aware about appropriate counseling and assisted reproductive methods
available for the management of endometriosis.
Yes, all post graduate trainees and senior house officers were educated about it.
Comments of trainee:
Assessment: mark/grade..
Date..
Date ..
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REFLECTIVE PRACTICE DOCUMENTATION-PERIPARTUM HYSTERETOMY
Mrs. Fathima Rizna, 29 years old, in her second pregnancy and had booking visit
at period of gestation of 12 weeks . Her previous pregnancy had uncomplicated
antenatal period, though it ended up as an emergency lower segment caesarean
section due to fetal distress. Birth weight was 3.1kg.At booking visit her dates
were confirmed by using crown rump length. She had offer shared care and
antenatal period was uneventful.
She was admitted at the period of gestation of 39 weeks and 6 days with
complaining of abdominal pain for one day duration. As she was counseled
regarding the vaginal birth after caesarean section in antenatal follow up and she
gave consent for vaginal birth after caesarean section. On examination growth of
the baby was adequate for period of gestation. Estimated fetal weight was 3.1
according to the ultra sound scan.
Following day she went into active labour in the morning and artificial rupture of
membrane done due poor progression however, it was not satisfactory even
7hours after the onset of labor. Therefore, decision was made to do an
emergency caesarean section. During the caesarean section it was noticed
lateral extension of the uterine incision. But person who did the caesarean
section was managed to achieve hemostasis at that time and closed the
abdomen. Six hour after caesarean section it was noticed that anuria for 2 hours,
severe abdominal tenderness, difficulty in breathing in lying position, clinically
pallor, pulse rate of 123bpm-1 and blood pressure of90/50mmHg, tachypnea and
dullness on the right flanks. No significant per vaginal bleeding was noted. Ultra
sound scan of the abdomen suggested 100cc free fluid right side of the abdomen
and uterine cavity was empty. All the detail raised the possibility of internal
bleeding and decided for a reopening.
In the laparotomy there was a large hematoma in right broad ligament, and
extended through para-colic gutter, up to lower border of the liver. Therefore, it
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was decided to go for total abdominal hysterectomy.3 pints of blood were
transfused. Postoperative recovery was uneventful.
During the suturing of uterine wall angle of right side of caesarean section had
been missed by the surgeon and that cause continuous bleeding and which
cause collection of blood in broader ligament.
During the reopening there was no attempt to preserve uterus by trying to find
the bleeding point and ligate it instead of total abdominal hysterectomy.
There was large hematoma in the right side of the abdomen and finding of
bleeder is difficult task. Furthermore patient was haemodynamicaly unstable.
Therefore, it was decided to do a total abdominal hysterectomy.
No
The entire doctors who are involved in obstetrics management should aware
about how to suture it when uterine incision extends during the caesarean
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section. Also they should have aware that when to seek help to prevent the
adverse outcome.
We have conducted the risk management meeting in our unit and discuss the
strategies to prevent these events in the future.
Comments of trainee:
Assessment: mark/grade..
Date..
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REFLECTIVE PRACTICE DOCUMENTATION- MANAGEMENT OF AN ECTOPIC
PREGNANCY
Mrs. G Samaranayaka a 35 year old patient got admitted with worsening right
sided abdominal pain for 1 day duration. She has undergone In- vitro fertilization
due to primary subfertility 8 weeks back, and has had per vaginal bleeding after
2 weeks of IVF. Serum beta HCG levels done at that time has revealed values of
15,19,30 iu on serial 48 hour measurements taken. Ultrasound has not revealed
any intra uterine or extra uterine pregnancy and she has been discharged with a
diagnosis of complete miscarriage. She has had mild intermittent bleeding after
that and presented to us 8 weeks after the IVF with worsening right sided
abdominal pain.
She has had regular menstruation previously with no heavy menstrual bleeding
or dysmenorrhea and she has underwent 6 intrauterine inseminations due to
male factor subfertility. She did not have any significant past medical history and
she has undergone a laparoscopy and tubal patency test 1 year back.
On examination she had mild pallor with a tachycardia, blood pressure was
normal and on vaginal examination cervix was firm, os was closed, uterus
retroverted and bulky with cervical motion tenderness.
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What problems did you see and observe?
35 year old patient with primary subfertility, presented with abdominal pain 8
weeks after IVF.
Although the beta HCG level was 480 patient was symptomatic and she had free
fluid in pouch of Douglas during the ultrasound.
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Expectant management is only be used for asymptomatic women with an
ultrasound diagnosis of ectopic pregnancy, with no evidence of blood in the
pouch of Douglas and decreasing hCG levels that are less than hCG 1000 iu/l at
initial presentation and less than 100 ml fluid in the pouch of Douglas.
Patients who dont have significant pain, un ruptured ectopic pregnancy with an
adenexial mass smaller than 35mm with no visible heart beat and serum HCG
less than 1500 iu can be considered for medical management with methotrexate.
Women who are unable to return for follow up or have any of the following
No
30
Summary of discussion with trainer:
Comments of trainee:
Assessment: mark/grade..
Date..
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Mrs. Jayani Rajika, a 25-year-old house wife, who is married for 9 months
presented with secondary amenorrhea for 7 months and fertility wishes.
She has attained menarche at 14 years of age and had regular
menstruation since then with no history of heavy menstrual loss or
dysmenorrhea. She had underwent laparoscopic left sided salpingectomy
for left sided tubal ectopic pregnancy 7 months back and has had absent
menstruation since then. She did not have a history of excessive stress,
weight loss, eating disorder or any headache or visual symptoms. She did
not have any nipple discharge, cyclical abdominal pain or symptoms of
hypothyroidism. She did not have any significant medical history or
surgical history other than the laparoscopy.
On examination her body mass index was 29, she had secondary sexual
characteristics, she did not have any features of hirsutism, acanthosis,
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goiter and rest of the general examination and systemic examination did
not reveal any significant findings.
On day 8 of the cycle, patient was reviewed with above investigations and
the transvaginal scan did not reveal any lead follicles. Diagnosis was
revised and a diagnosis of multicystic ovaries due to hypothyroidism was
made and the patient was referred to endocrinologist to start on thyroxin
therapy
According to her history and examination the patient did not have
symptoms of hypothalamic or pituitary cause of amenorrhea.
Although patient was 25 years old and subfertility treatment was started
with ovulation induction as the initial running diagnosis was polycystic
ovary syndrome.
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What did you learn from this experience?
Oligomenorrhoea/amenorrhea
Hyperandrogenism (clinical or biochemical)
Polycystic ovaries on ultrasound (ovary with 12 or more
follicles measuring 2 - 9 mm in diameter or increases ovarian
volume > 10cm3
Of which this patient had amenorrhea and ultrasound findings of less than
12 follicles and her ovarian volume was also normal. Furthermore, overt as
well as subclinical hypothyroidism both can give rise to multicystic ovaries
and anovulation.
I will not be diagnosing polycystic ovary syndrome off handedly and will
be using the Rotterdam criteria to diagnose polycystic ovary syndrome will
keep in mind that hypothyroidism associated with multicystic ovaries is an
another cause for anovulation when working out differential diagnosis for
a patient with anovulation.
No
That I need to carry out more case based discussions in the future
33
I did a case based discussion with my trainer and discussed this case at
the monthly clinical meeting at Sri Jayewardenepura General Hospital
where I was able to get inputs from other specialties
Comments of trainee:
Assessment: mark/grade..
Date..
Date ..
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REFLECTIVE PRACTICE DOCUMENTATION-MANAGEMENT OF AN OVARIAN
MALIGNANCY
Prepared the patient for primary debulking surgery with adjuvant therapy
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Justification for what you did.
The overall five year survival for stage 111 to 1V ovarian carcinoma is 30
to 40 %. As the survival of patients with primary debulking surgery is
shown to be better than those with who unerdgo chemotherapy alone
decision was made to perform primary debulking surgery.
Regarding the age and overall condition of the patient, biopsy and neo
adjuvant therapy would have been a better option under the
circumstances.
how to manage the side effects of both the disease and its
treatments in order to maximize wellbeing
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How to deal with emotions such as sadness, depression, anxiety and
a feeling of a lack of control over the outcome of the disease and
treatment.
Chemotherapy or upfront surgery for newly diagnosed advanced ovarian cancer; results
from the MRC CHORUS trial. J clin oncol 31,2013 (suppl:abstr550)
Nice guidelines (CG122)
No, I learned the management options of advanced ovarian carcinoma from this experience
No
That I need to carry out more case based discussions in the future
I did a case based discussion with my trainer and discussed with post
graduate trainees
Comments of trainee:
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Assessment: mark/grade..
Date..
Date ..
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