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Obgyn Clinical Cases PDF
Obgyn Clinical Cases PDF
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TABLE OF CONTENTS / LINKS TO INDIVIDUAL CASES
1. History
2. Examination
3. Pap Smear and Cultures
4. Personal Interaction / Communication Skills
5. Legal Issues / Ethics in Obstetrics & Gynecology
6. Preventive Care and Health Management
7. Maternal-Fetal Physiology
8. Preconception Care
9. Antepartum Care
10. Intrapartum Care
11. Immediate Care of the Newborn
12. Postpartum Care
13. Lactation
14. Ectopic Pregnancy
15. Spontaneous Abortion
16. Medical & Surgical Conditions in pregnancy
17. Preeclampsia-Eclampsia Syndrome
18. Isoimmunization
19. Multifetal Gestation
20. Fetal Death
21. Abnormal Labor
22. Third-Trimester Bleeding
23. Preterm Labor
24. Premature Rupture of Membranes
25. Intrapartum Fetal Surveillance
26. Postpartum hemorrhage
27. Postpartum Infection
28. Anxiety and Depression
29. Postterm Pregnancy
30. Fetal Growth Abnormalities
31. Obstetric Procedures
32. Contraception and Sterilization
33. Abortion
34. Vulvar and Vaginal Disease
35. Sexually Transmitted Infections & Urinary Tract Infections
36. Pelvic Relaxation & Urinary Incontinence
37. Endometriosis
38. Chronic Pelvic Pain
39. Disorders of the Breasts
40. Gynecological Procedures
41. Puberty
42. Amenorrhea
43. Hirsutism and Virilization
44. Normal and Abnormal Uterine Bleeding
45. Dysmenorrhea
46. Climacteric / Menopause
47. Infertility
48. Premenstrual Syndrome & Premenstrual Dysphoric Disorder
49. Gestational Trophoblastic Neoplasia
50. Vulvar Neoplasms
51. Cervical Disease and Neoplasia
52. Uterine Leiomyomas
53. Endometrial Carcinoma
54. Ovarian Neoplasms
55. Sexuality and Modes of Sexual Expression
56. Sexual Assault
57. Domestic Violence
UNIT ONE:
1. History
2. Examination
3. Pap Smear and Cultures
4. Personal Interaction / Communication Skills
5. Legal Issues / Ethics in Obstetrics & Gynecology
6. Preventive Care and Health Management
TEACHING TOOL 1
History
This tool is designed to help the teacher lead an interactive session during which the
students collectively develop a history taking format they can practice and internalize
throughout the rotation. It is geared to taking a complete gynecologic history.
3. It is a skill that students can actually do, giving them a legitimate role on the
health care team and building self-esteem
QUESTION 1:
ANSWER:
QUESTION 2:
ANSWER:
Going around the room, the students create a list of around 30-40 reasons girls and
women seek gynecologic care. It helps set the stage for what they will be expected to
learn the rest of the rotation. Their list typically includes:
Indicate that each item they have listed has its own unique HPI.
Describe what you want to hear at the beginning of every HPI, i.e.
“The patient is a 26 year old gravida X para Y with a last menstrual period on
DATE here today for . . . “
Introduce helpful mnemonics, i.e. “An Alphabet of Pain for the HPI”
P = Pain
Q = Quality
R = Region and radiation
S = Severity
T = Timing
U = Undiagnosed?
V = Vomiting and other associated symptoms
W = What makes it better /worse
QUESTION 4: What is the next component of the history during this rotation?
Then present this to the students in the format and order you want them to collect and
recorded during the rotation.
QUESTION 5: What are the next components of the history that you will need to collect?
Answer: Record these on the board in the order you want them collected and
presented during the rotation:
QUESTION 6: Small group activity. Break the students into the following four groups:
Each group generates a list of ten common diseases or conditions that they can
specifically ask their patients about in their assigned area. When all of the
groups are done (5-10 minutes), they report these back to the group as a whole.
Teacher records lists on the board.
Past Medical History - Lists typically include:
From this list (limit to 10), brainstorm why each disease matters to a practicing
ob-gyn. Issues typically include associated menstrual abnormalities, symptoms
mimicking gynecologic conditions, potentially teratogenic therapies, high-risk
pregnancy status, operative risks and impact on birth control decisions.
From this list (limit to 10), brainstorm why each disease matters to a practicing
ob-gyn. Issues typically include anesthetic complications, bleeding
abnormalities, blood transfusions and post-operative intra-abdominal
adhesions.
From this list (limit to 10), brainstorm why each disease matters to a practicing
ob-gyn. Issues typically include associated menstrual abnormalities, symptoms
mimicking gynecologic conditions, therapy during pregnancy and lactation, birth
control options and associations with prior abuse histories.
From this list (limit to 10), brainstorm why each disease matters to a practicing
ob-gyn. Issues typically include inheritance patterns and impacts on personal
health care decision-making.
If time permits, review the myriad impacts of smoking on reproductive health, i.e.
Menstrual irregularity
Premature menopause
Infertility
Miscarriage
IUGR
PROM
PTL/PTD
Cervical dysplasia/carcinoma
Conclusion:
Show the students the template they have collectively developed. Encourage them to
practice using it over and over and over again so that it is completely internalized by
the end of the rotation.
CLINICAL CASE 2
Examination
52-year-old female comes in for annual gynecologic exam. She stopped menstruating
two years ago and has experienced hot flashes and some insomnia. She, however, feels
she is doing well and is not interested in HRT. Menarche was at age 13, menses were
regular until last year prior to cessation of menses, but then she stopped and has had no
more bleeding since that time. She had two pregnancies and two vaginal births; her
children are 25 and 28.
Her ROS is negative except for occasional loss of a small amount of urine in her aerobics
class; if she is careful to empty her bladder prior to class, this isn’t a problem. She is
sexually active and needs to use a lubricant; however, sex is not painful.
PMH is negative except for an appendectomy and breast biopsy, which was negative.
She is married in a good relationship with no history of abuse and she exercises
3x/week in aerobics class or walks. She drinks a glass of wine with dinner and has
never smoked or used illicit drugs. She drinks 3 glasses of milk/day. Family history is
significant for mother with osteoporosis, sister with hypothyroidism and father with
elevated cholesterol.
Physical exam
Thyroid-WNL; Lungs- Clear; COR- RRR no murmur or gallops; Breast exam – breasts are
symmetrical with fibrocystic changes in the upper out section of each breast; no distinct
masses are noted with evidence of small scar on R breast; Abdomen – soft non-tender;
Ext genitalia – normal with evidence of midline scar consistent with vagina – no lesions,
slightly atrophic; Cervix appears to be WNL and Pap smear obtained. The speculum is
taken apart and the lower blade of the speculum is used by placing in the vagina
pressing downward to evaluate the anterior wall of the vagina. There is evidence of
small cystocele and urethrocele, which descends slightly with Valsalva, but not to the
introitus. There is no loss of urine during this maneuver. Bimanual reveals an
anteverted uterus with no adnexal masses palpate. In fact, the adnexa are not well
appreciated, recto-vaginal exam is negative, confirms the vaginal exam and the stool is
heme negative.
You assure the patient that her exam is WNL. You begin counseling her re: lifestyle
issues, encourage her to continue exercising regularly and perhaps add some weights to
further decrease risk of osteoporosis. You counsel her regarding her needs for 1200 mg
of calcium/day. Additionally, she should consider either a sigmoidoscopy or
colonoscopy for colorectal screening. A mammogram is ordered, as well as screening
cholesterol and thyroid screen. She is counseled regarding her Kegel exercises and need
to keep bladder empty during exercise and to do Kegels to strengthen pelvic floor. She
is sent out with a slip for cholesterol screening, thyroid screening, urinalysis and a set of
three fecal occult blood cards.
Discussion/teaching points
The annual exam is more than just a breast exam and pelvic exam. It is the opportunity
to assess a patient’s overall health and health care needs. The same exam/laboratory
tests are not done on each patient. One needs to consider age and risk factors when
deciding what to do. This patient is 52-years-old; therefore, it is important to include
colorectal screening and counseling in the exam. She should also have annual
mammography, counsel regarding calcium intake and consider thyroid screening.
Although SBE has not been shown to decrease morbidity or mortality from breast
cancer, one should inquire if the patient does SBE and offer to teach her if she doesn’t
know how to do this.
PE findings of urethrocele and mild cystocele are very common in older women who
have had children. This is best detected on physical exam using a Sims speculum and
having the patient Valsalva. This allows one to examine the movement and degree of
prolapse of the anterior and posterior vaginal wall, as well as the cervix. A ureterocele,
cystocele and rectocele do not necessarily require surgical repair. Mild symptoms of
stress urinary incontinence, such as this patient reports, need to be addressed and
usually respond well to behavioral measures, such as keeping the bladder empty during
exercise and minimizing caffeinated beverages and to pelvic strengthening exercises or
Kegels.
On pelvic exam, the adnexa were not well appreciated, which is normal in
postmenopausal women. Often the adnexa are not felt and, if they are palpated, might
raise concern and necessitate further evaluation if thought to be enlarged. The
rectal/vaginal is done to confirm the findings of the vaginal exam and is important in
this age patient to evaluate for rectal cancers. Approximately 10% of rectal cancers can
be detected with rectal exam. However, it is important to add fecal occult blood testing,
which should not only be done at the time of the exam, but the patient also needs to do
this at home on three consecutive bowel movements. This will increase detection of all
colorectal cancers.
TEACHING CASE 3
Clinical Case:
JA is a 22-year-old G0 female who presents for an annual exam. She had an abnormal
Pap smear 4 years ago followed by a colposcopy but no biopsies were performed. Her
follow-up Pap smears were normal and the last one was 2 years ago. She is currently
sexually active with a new partner for the last 2 months, and has had four lifetime
partners. She does not report any history of sexually transmitted disease. She is
currently using birth control pills for contraception. She is just finishing her menstrual
cycle and is spotting; her periods are regular without problems. Her review of systems
is negative. She smokes one pack of cigarettes per week; she does not drink and states
that she has occasionally used marijuana. She is a freshman in college and is majoring in
business. Her vitals and physical exam are normal.
Discussion Questions:
2. In addition to performing a Pap smear, what cultures might you recommend for
4. What risk factors does this patient have for cervical dysplasia and cancer?
5. If while performing the speculum exam, you notice a gross lesion on the cervix,
6. What other counseling or advice you need to discuss with this patient?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 1 Health Care for Women. Pages 16-
24.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 2 Clinical
Approach to the Patient. Pages 14-18.
Pap Smear and Cultures
Preceptor Handout
The Pap smear is one of the most effective screening tests used in medicine today. Proper
technique in performing the Pap smear and obtaining specimens for microbiologic culture
will improve accuracy.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
JA is a 22-year-old G0 female who presents for an annual exam. She had an abnormal
Pap smear 4 years ago followed by a colposcopy but no biopsies were performed. Her
follow-up Pap smears were normal and the last one was 2 years ago. She is currently
sexually active with a new partner for the last 2 months, and has had four lifetime
partners. She does not report any history of sexually transmitted disease. She is
currently using birth control pills for contraception. She is just finishing her menstrual
cycle and is spotting; her periods are regular without problems. Her review of systems
is negative. She smokes one pack of cigarettes per week; she does not drink and states
that she has occasionally used marijuana. She is a freshman in college and is majoring in
business. Her vitals and physical exam are normal.
Discussion Questions:
a. Discuss conventional Pap smear and Thin Prep: Both collected from the
endocervical canal and transformation zone with spatula and cytobrush.
Do not use any gel prior to performing the Pap smear.
b. Thin prep has a higher sensitivity rate
c. Discuss the importance of properly labeling specimens and sending off to
promptly to the lab.
2. In addition to performing a Pap smear, what cultures might you recommend for
this patient, and how do you proceed in obtaining them?
a. Since the patient is sexually active with a new partner, you should offer
her screening for sexually transmitted diseases including performing
endocervical cultures or DNA probe for gonorrhea and Chlamydia.
b. After performing the Pap smear, you wipe any excess cervical mucous
and you insert the cotton swab to collect the cultures or the DNA probe in
the endocervical canal.
3. How often does this patient need to undergo a Pap smear?
a. Patients who have had an abnormal Pap smear previously, will need
more frequent Pap smears based on the actual abnormality. For this
patient, since it appears that she had normal follow-up, she needs to
continue to have annual Pap smears assuming this one is normal.
b. For monogamous patients who have had 3 normal Pap smears in a row,
may space out the Pap smears to once every 2-3 years.
4. What risk factors does this patient have for cervical dysplasia and cancer?
5. If while performing the speculum exam, you notice a gross lesion on the cervix,
what would your next step in management be?
a. Any gross lesion on the cervix will need to be directly biopsied as Pap
smears have a false negative rate and cervical cancer might be missed.
6. What other counseling or advice you need to discuss with this patient?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 1 Health Care for Women. Pages 16-
24.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 2 Clinical
Approach to the Patient. Pages 14-18.
CLINICAL CASE 4
A 30-year-old female returns to the busy hospital clinic to get the results of her Pap
smear. She has had a Pap smear every other year since age 20 – all with normal results.
Reviewing her chart, you see that she has been married for three years and has no
children. She smokes two packs of cigarettes a week and is currently on oral
contraceptives. She has no history of sexually transmitted diseases and appears to have
a very conservative sexual history.
Your supervising resident has been rushing from room to room and is now heading
your way. Upon questioning, you explain to the resident that you understand the
diagnosis and the next course of action. You enter the room and the patient is sitting in
the chair. With both of you standing in front of the patient, the conversation between
the resident and the patient is as follows:
Resident: Hi, I’m Dr. Jones and this is _______, one of our medical students.
Patient: Hello
Resident: (Full eye contact with the patient) As you know, we always have patients return to
get the results of their Pap smear when things don’t turn out as well as we would like.
Resident: (Speaking rather rapidly, steps back slightly, crosses arms, maintains eye contact) In
your case, the results show HGSIL – that means a high-grade squamous intraepithelial lesion.
Patient: (Remains silent; squirms a little in her chair; now looks frightened)
Resident: While I can’t say exactly what caused this result, I can tell you that several factors
can play role, including smoking, oral contraceptive use, experience with multiple sexual
partners and, of course, having a male partner with multiple consorts.
Resident: (Maintains eye contact, except for glancing at you a couple of times) Our standard
protocol is to have a colposcopy with endocervical curettage and directed biopsies as indicated.
There really isn’t anything to worry about. On your way out, please stop at the front desk to
arrange your appointment. Of course, if you have any questions after you get home, please feel
free to call the clinic. (Looking at the clock on the wall), I’m sorry I have to run, but we have a
very full clinic this morning.
The resident glances at you and leaves the room. You quickly assess what you need to do next.
Diagnosis/Management
The table below is an evaluation of how well the resident interacted with this patient.
Look closely at this evaluation and determine whether you agree with it. If not, how
would you evaluate the interaction? In other words, how would you diagnosis the
interaction and what would be your management plan for such an interaction?
1. How do you think the resident would answer you if you asked how the
visit with this patient went? In other words, what do you think would be
the resident’s perception of this conversation?
2. What do you believe would be the patient’s perception of this
conversation?
3. Given the setting and atmosphere, would you approach the patient
differently?
4. What was done to establish rapport with the patient? Could more have
been done?
5. What can you glean from the patient’s body language and from what she
said or, perhaps, didn’t say?
6. Did the resident “treat the whole patient?”
7. While “what” the resident said may be accurate, what impact might it
have on the patient and why? (Suggest you take it comment by comment).
If you had to evaluate this information exchange, what would be your criteria?
Construct a new table with your criteria and apply it to this case scenario.
Now that you have thought all of this through, what would you do if you were the
medical student who has been left alone with the patient when the resident exited?
Teaching points:
The most important difference between a good and indifferent clinician lies in the amount
of attention paid to the story of a patient. —Farquhar Buzzard
Students can generate these and additional points and apply them to the case scenario.
TEACHING CASE 5
Clinical Case:
A 33 year-old G2P1 Caucasian patient at 33 weeks gestation presents to your office for
her scheduled prenatal visit. She reports no problems. Her psychosocial history is
unremarkable. Her prior pregnancy resulted in a cesarean delivery with a transverse
incision. There were no complications associated with the delivery. Her physical
examination reveals normal blood pressure and weight. Fundal height, fetal position,
and heart rate are unremarkable. Her diagnostic test results show Hgb: 12.4 g/dL; WBC:
11,000; Urinalysis: negative for bacteria and leucocytes; and urine drug screen:
negative.
Discussion Questions:
1. What would you tell this patient regarding her options for delivery?
6. What should be done if the patient declines a trial of labor after a history of low-
transverse c-section?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 2 Ethics in Obstetrics and
Gynecology. Pages 25-29.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004;
Chapter 1 Practice Management and Ethics in Obstetrics and Gynecology. Pages 3-8.
Chapter 5 Clinical Performance Improvement: Assessing the Quality and Safety of Women’s Health
Care. Pages 46-54.
Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies (4th ed.). Philadelphia:
Churchill-Livingstone, 2002. pp. 146-150, 585-587.
Legal and Ethical Issues in Obstetrics and Gynecology
Preceptor Handout
Rationale: Legal obligations to protect patients’ interests are effective only if understood
and applied. Recognizing and understanding the basis of ethical conflicts in obstetrics and
gynecology will allow better patient care and prevent critical errors in treatment
planning.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
A 33 year-old G2P1 Caucasian patient at 33 weeks gestation presents to your office for
her scheduled prenatal visit. She reports no problems. Her psychosocial history is
unremarkable. Her prior pregnancy resulted in a cesarean delivery with a transverse
incision. There were no complications associated with the delivery. Her physical
examination reveals normal blood pressure and weight. Fundal height, fetal position,
and heart rate are unremarkable. Her diagnostic test results show Hgb: 12.4 g/dL; WBC:
11,000; Urinalysis: negative for bacteria and leucocytes; and urine drug screen:
negative.
Discussion Questions:
1. What would you tell this patient regarding her options for delivery?
6. What should be done if the patient declines a trial of labor after a history of low-
transverse c-section (VBAC)?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 2 Ethics in Obstetrics and
Gynecology. Pages 25-29.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004;
Chapter 1 Practice Management and Ethics in Obstetrics and Gynecology. Pages 3-8.
Chapter 5 Clinical Performance Improvement: Assessing the Quality and Safety of Women’s Health
Care. Pages 46-54.
Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies (4th ed.). Philadelphia:
Churchill-Livingstone, 2002. pp. 146-150, 585-587.
TEACHING CASE 6
Clinical Case:
A 51-year old G3P3 woman comes to the office for a health maintenance exam. She has
no concerns. She is in good health. She had three normal vaginal deliveries. She is
sexually active with her husband and has been using condoms for contraception. She
has no history of abnormal Pap smears or sexually transmitted diseases. Her last Pap
smear was one year ago.Her cycles are irregular as she only had 4 menstrual periods
last year. Her last menstrual period was 2 months ago. She is not taking any
medications. Her family history is significant for a maternal aunt who was diagnosed
with ovarian cancer at age 60. On examination, she has normal vital signs. Her heart,
lungs and abdominal exams are normal. On pelvic examination, she has normal
external genitalia, normal vagina and cervix. On bimanual exam, she has a slightly
enlarged uterus and no palpable adnexal masses. Rectovaginal exam confirms.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 1 Health Care for Women. Pages 3-
11.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition,2004; Chapter 2 Clinical
Approach to the Patient. Pages 9-10.
Preventive Care and Health Maintenance
Preceptor Handout
The student will recognize the value of routine health surveillance as a part of health
promotion and disease prevention.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
A 51-year old G3P3 woman comes to the office for a health maintenance exam. She has
no concerns. She is in good health. She had three normal vaginal deliveries. She is
sexually active with her husband and has been using condoms for contraception. She
has no history of abnormal Pap smears or sexually transmitted diseases. Her last Pap
smear was one year ago. Her cycles are irregular as she only had 4 menstrual periods
last year. Her last menstrual period was 2 months ago. She is not taking any
medications. Her family history is significant for a maternal aunt who was diagnosed
with ovarian cancer at age 60. On examination, she has normal vital signs. Her heart,
lungs and abdominal exams are normal. On pelvic examination, she has normal
external genitalia, normal vagina and cervix. On bimanual exam, she has a slightly
enlarged uterus and no palpable adnexal masses. Rectovaginal exam confirms.
Discussion Questions:
In theory, this patient can still get pregnant since she is still menstruating. However,
the irregular cycles indicate perimenopausal status and the extremely low
likelihood of pregnancy.
At this age, the patient does not need a bone density scan as she does not have any
additional risk factors for osteoporosis. In addition to age, gender, and race, risk
factors for osteoporosis include: Family or personal history of fractures as an adult,
bone structure and body weight, menopause and menstrual history, lifestyle, certain
medications and chronic diseases.
4. What are your recommendations regarding the frequency of Pap Smears for this
patient?
This patient needs a Pap Smear every 3 years since she has never had an abnormal
Pap Smear and her last one was one year ago.
5. How would the recommendations for the Pap smear be different if this patient was
32 years of age?
They would not be any different if she did not have any additional risk factors.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 1 Health Care for Women. Pages 3-
11.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition,2004; Chapter 2 Clinical
Approach to the Patient. Pages 9-10.
UNIT TWO:
SECTION A
7. Maternal-Fetal Physiology
8. Preconception Care
9. Antepartum Care
10. Intrapartum Care
11. Immediate Care of the Newborn
12. Postpartum Care
13. Lactation
CLINICAL CASE 7
Maternal-Fetal Physiology
A 22-year-old married woman calls your office because she is 4 days late for her
menstrual period. She has told your nurse that her menstrual periods are always
between 27-30 days apart, and usually last 4-5 days. She and her husband have not
been using contraception for 4 months. She has performed a home urine pregnancy test
and it is positive. How likely is it that the home test is incorrect?
She makes an appointment to be seen in your office for her first prenatal visit within the
next 2 weeks. You advise her to continue her prenatal vitamins that she has been taking
for the last 3 months. What component of the prenatal vitamins is the most important in
preventing birth defects?
Even though this is her first pregnancy, she understands that she will not have further
menstrual periods until after delivery. What is the physiological explanation for
amenorrhea during pregnancy?
She also understands that she will gain weight during pregnancy. What is a normal
weight gain for an average-sized woman and what are the components of that weight
gain?
Her initial prenatal visit is uneventful and a 6-week intrauterine gestation is confirmed.
Within the next two weeks, she notes the onset of early morning nausea, heartburn and
reflux. Later in the pregnancy, she experiences constipation and the development of
hemorrhoids. What hormone is most closely related to these pregnancy-related
concerns, and why?
Her initial hematocrit of 36% drops to 33% at 28 weeks gestation in spite of regular
prenatal vitamin and supplemental iron therapy. Why?
At her 20-week visit, she describes some dyspnea at rest, but no exercise intolerance,
saying she can still run 3-5 miles daily. What physiological process could explain this
dyspnea?
At her 24-week gestational age visit, she describes urinary frequency and her urinalysis
at that visit shows a trace of glucose. Can these changes be normal during pregnancy?
Should she be screened for diabetes at this time?
At that same visit, she wants to discuss the process of labor. She is not sure she
understands when to come to the hospital when contractions start, and wants to
confirm her due date. She also asks what will happen if she does not delivery by her
due date.
Teaching points:
It is important for health care workers to recognize the normal physiological changes
that occur to the woman during pregnancy. It is also critical to recognize those signs
and symptoms that may occur during pregnancy that are NOT normal physiological
changes. Because most pregnancies are straightforward and routine, any sign or
symptom that is not one with which you are familiar (if you treat many pregnant
patients), or which you do not find described in any standard treatise about pregnancy
(if you do not routinely treat pregnant patients) should be managed with great care and
with appropriate evaluation. Frequently, maternal or fetal catastrophes may be
prevented or ameliorated by the early detection and treatment begun by the alert
practitioner.
TEACHING CASE 8
Preconception Care
Student Handout
Clinical Case:
You have been Mary’s doctor for the past 3 years. She is a 39-year-old Caucasian woman
with a BMI of 32.9 who sees you primarily for her idiopathic chronic hypertension,
which is well controlled on an ACE inhibitor. She has smoked 1 pack of cigarettes per
day for the past 20 years. She is in today for her annual exam and mentions that she is
getting married in a few months and would like to start a family. She has never been
pregnant before. Her past medical history is otherwise unremarkable.
On physical exam, her BP=138/84, Ht=5’ 2”, Wt=180 lbs. Otherwise, her exam is
unremarkable.
Discussion Questions:
2. What are the major topics that should be discussed with any woman prior to
conception?
3. For the patient in this case, what specific topics need to be addressed?
References:
Obstetrics and Gynecology by 5th Edition, 2006; Chapter 3 Embryology, Anatomy, and Reproductive
Genetics. Pages 39-47.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition,2004; Chapter 8 Antepartum
Care: Preconception and Prenatal care, Genetic Evaluation and Teratology, and Antenatal Fetal Assessment.
Pages 83-85.
ACOG Committee Opinion No. 313, September 2005 The Importance of Preconception Care in the
Continuum of Women’s Health Care.
Preconception Care
Preceptor Handout
Rationale: The proven benefits of good health prior to conception include a significant
reduction in maternal and fetal morbidity and mortality.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
You have been Mary’s doctor for the past 3 years. She is a 39-year-old Caucasian woman
with a BMI of 32.9 who sees you primarily for her idiopathic chronic hypertension,
which is well controlled on an ACE inhibitor. She has smoked 1 pack of cigarettes per
day for the past 20 years. She is in today for her annual exam and mentions that she is
getting married in a few months and would like to start a family. She has never been
pregnancy before. Her past medical history is otherwise unremarkable.
On physical exam, her BP=138/84, Ht=5’ 2”, Wt=180 lbs. Otherwise, her exam is
unremarkable.
Discussion Questions:
2. What are the major topics that should be discussed or addressed with any woman
prior to conception?
3. For the patient in this case, what specific topics need to be addressed?
References:
Obstetrics and Gynecology by 5th Edition, 2006; Chapter 3 Embryology, Anatomy, and Reproductive
Genetics. Pages 39-47.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition,2004; Chapter 8 Antepartum
Care: Preconception and Prenatal care, Genetic Evaluation and Teratology, and Antenatal Fetal Assessment.
Pages 83-85.
ACOG Committee Opinion No. 313, September 2005 The Importance of Preconception Care in the
Continuum of Women’s Health Care.
TEACHING CASE 9
Antepartum Care
Student Handout
Clinical Case:
Your resident asks you to make a preliminary assessment of a 24-year-old woman who
has presented to the emergency room complaining of vaginal spotting for the past two
days, and which has become heavier today. She says that today’s bleeding is more than
a usual period and she became concerned when she passed a large clot. When you enter
the cubicle where she is resting, you notice an anxious, though pleasant, woman sitting
upright on the gurney. She denies fever, chills, abdominal pain or cramping. She says
that she has been urinating more frequently than usual, without pain, and notes fatigue
that she attributes to stress at her work as a pastry chef. She is unable to tell you when
her last menstrual period was since she has had irregular menses since puberty, often
with two to three-month gaps between periods. She has never been pregnant. She tells
you that she and her boyfriend, who plan to marry in the next year, use condoms for
contraception. She has never been diagnosed with a sexually transmitted infection.
The patient is 170 pounds and is 5’5” tall. On physical exams, her vital signs are stable
and she is not orthostatic. Speculum exam reveals no active bleeding from the cervix,
although there is evidence of old blood in the vaginal vault. The cervical os is closed. No
lesions are present in the vagina or on the vulva. Bimanual exam reveals a slightly
enlarged and globular uterus in mid-position, slightly irregular in contour but non-
tender; the adnexae are without masses and tenderness.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 5 Antepartum Care. Pages 63-78.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 8 Antepartum
Care: Preconception and Prenatal care, Genetic Evaluation and Teratology, and Antenatal Fetal Assessment.
Pages 83-103.
Antepartum Care
Preceptor Handout
Rationale: Antepartum care promotes patient education and provides ongoing risk
assessment and development of an individualized patient management plan.
The APGO Educational Objectives related to this topic are the following:
A. Diagnose pregnancy*
B. Assess gestational age*
C. Distinguish an at-risk pregnancy*
D. Assess fetal growth, well-being, maturity and amniotic fluid volume
E. Describe appropriate diagnostic studies
F. Describe nutritional needs of pregnant women
G. Describe adverse effects of drugs and the environment
H. Perform a physical examination on obstetric patients*
I. Answer commonly asked questions concerning pregnancy and labor and
delivery
J. Counsel women with an unintended pregnancy
Clinical Case:
Your resident asks you to make a preliminary assessment of a 24-year-old woman who
has presented to the emergency room complaining of vaginal spotting for the past two
days, and which has become heavier today. She says that today’s bleeding is more than
a usual period and she became concerned when she passed a large clot. When you enter
the cubicle where she is resting, you notice an anxious, though pleasant, woman sitting
upright on the gurney. She denies fever, chills, abdominal pain or cramping. She says
that she has been urinating more frequently than usual, without pain, and notes fatigue
that she attributes to stress at her work as a pastry chef. She is unable to tell you when
her last menstrual period was since she has had irregular menses since puberty, often
with two to three-month gaps between periods. She has never been pregnant. She tells
you that she and her boyfriend, who plan to marry in the next year, use condoms for
contraception. She has never been diagnosed with a sexually transmitted infection.
The patient is 170 pounds and is 5’5” tall. On physical exams, her vital signs are stable
and she is not orthostatic. Speculum exam reveals no active bleeding from the cervix,
although there is evidence of old blood in the vaginal vault. The cervical os is closed. No
lesions are present in the vagina or on the vulva. Bimanual exam reveals a slightly
enlarged and globular uterus in mid-position, slightly irregular in contour but non-
tender; the adnexae are without masses and tenderness.
Discussion Questions:
In a woman of childbearing age who presents with an unknown last menstrual period, it
is important to determine her pregnancy status. A history of irregular menses is not
uncommon, especially in teenagers or in overweight women and, in this setting, a
qualitative urine pregnancy test is crucial. The diagnosis of pregnancy should not be
made on nonspecific signs and symptoms.
The CBC and UA are normal. The urine pregnancy test is positive.
With a known pregnancy, the next steps are to determine if it is intrauterine or ectopic,
viable or non-viable. The physical examination is important in ruling out adnexal masses
or pain that indicate a possible ectopic pregnancy. Uterine size is a clue to the presence
of an intrauterine pregnancy, though fibroids (leiomyomata) or adenomyosis can also
cause uterine enlargement. Typically, pregnancy size is given in terms of the estimated
gestational age or the size of fruit, with a six to eight-week size uterus the size of a large
orange, 12-14 weeks that of a grapefruit, and 14-16 weeks the size of a cantaloupe. A
12-week size uterus can be felt at the symphysis pubis and a 20-week size pregnancy
reaches the level of the umbilicus.
The accepted norm for pregnancy dating in the absence of a firm last menstrual period
date is the ultrasound. In addition, the ultrasound will help determine whether the
pregnancy is viable and whether it is intrauterine or not. A rule of thumb is the earlier
the ultrasound, the more reliable as far as dating. In practice, many ultrasounds are
performed at about 16-20 weeks gestation, which ensures both accurate dating and the
opportunity of evaluating the fetal for developmental abnormalities. The later in
pregnancy an ultrasound is performed, the less reliable is its dating ability, due to the
variance is fetal size with advancing gestation.
This patient’s history of painless vaginal bleeding is common. If the pregnancy test is
positive and an intrauterine pregnancy is not identified then the patient needs to be
further evaluated to rule out an ectopic pregnancy. With an early intrauterine
pregnancy, it is not always clear why this bleeding occurs; it may be due to bleeding
from a friable cervix or to bleeding from implantation of the pregnancy onto the uterine
wall. Painless vaginal bleeding early in pregnancy commonly resolves spontaneously
and does not recur. In those women who experience cramping as well as bleeding, the
risk of spontaneous abortion (miscarriage) is increased. Patients with cramping and
bleeding may require closer monitoring with repeat ultrasounds or perhaps repeat
QhCG levels until the symptoms resolve and the risk of miscarriage decreases, usually
after the first trimester. If a spontaneous abortion is diagnosed, appropriate steps are
taken to manage this situation.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 5 Antepartum Care. Pages 63-78.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 8 Antepartum
Care: Preconception and Prenatal care, Genetic Evaluation and Teratology, and Antenatal Fetal Assessment.
Pages 83-103.
TEACHING CASE 10
Intrapartum Care
Student Handout
Clinical Case:
AJ is a 23-year old G1P0 currently at 38 weeks gestation who comes to Labor and
Delivery complaining of a 5 hour history of mild contractions occurring every 7 – 15
minutes and lasting 30-45 seconds in duration. Her antepartum course has been
uncomplicated. She denies leaking of fluid per vagina, bloody show or vaginal bleeding.
She reports normal fetal movement.
VS: BP= 105/65, pulse = 95, respirations=18. The patient is placed on a fetal heart rate
monitor which reveals a reassuring pattern. The tocodynamometer confirms irregular
contractions every 7-15 minutes. The patient’s cervix is 1-2 cm dilated, 50% effaced
with the fetal vertex at 0 station.
Discussion Questions:
5. Discuss the steps of vaginal delivery beginning with the cardinal movements.
6. What are other methods of delivery if AJ had not been able to push effectively or
if fetal intolerance of labor had developed?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 6 Intrapartum Care. Pages 79-94.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 9 Normal
Labor, Delivery, and Postpartum Care. Pages 104-135.
Intrapartum Care
Preceptor Handout
Rationale: Understanding the process of normal labor and delivery allows optimal care
and reassurance for the parturient and timely recognition of abnormal events.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
AJ is a 23-year old G1P0 currently at 38 weeks gestation who comes to Labor and
Delivery complaining of a 5 hour history of mild contractions occurring every 7 – 15
minutes and lasting 30-45 seconds in duration. Her antepartum course has been
uncomplicated. She denies leaking of fluid per vagina, bloody show or vaginal bleeding.
She reports normal fetal movement.
VS: BP= 105/65, pulse = 95, respirations=18. The patient is placed on a fetal heart rate
monitor which reveals a reassuring pattern. The tocodynamometer confirms irregular
contractions every 7-15 minutes. The patient’s cervix is 1-2 cm dilated, 50% effaced
with the fetal vertex at 0 station.
Discussion Questions:
If possible have a bony pelvis model or plastic pelvic model and model
fetus available to have student demonstrate the steps of vaginal delivery
(shows how).
6. What are other methods of delivery if AJ had not been able to push effectively or if
fetal intolerance of labor had developed
Forceps
Vacuum
Cesarean section
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 6 Intrapartum Care. Pages 79-94.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 9 Normal
Labor, Delivery, and Postpartum Care. Pages 104-135.
CLINICAL CASE 11
C.C. is a term male newborn infant at 5 minutes of age. The Apgar score assigned by the
charge nurse at 1 minute was 4. Currently, he has a heart rate of 110, a vigorous cry,
active motion of all four extremities, bluish hands and feet, and a positive grimace.
Because of the low 1-minute Apgar score, the charge nurse sent cord gas. The following
umbilical arterial gas measurements were noted: pH 7.14, pCO2 69 mm Hg, HCO3 21.
Discussion
Apgar scores are a useful aid to evaluate the clinical status of the newborn and the need
for resuscitation. The 1-minute Apgar score is used to identify an infant’s need for
immediate resuscitation. An infant with a score of 4-6 at 1 minute demonstrates
depressed respiration, flaccidity and poor color. In general, these infants respond to
stimulation and do not need resuscitation efforts, i.e. ventilation. The Apgar Scoring
System is reflected in the following table:
A recent investigation on the continuing value of the Apgar score studied greater than
13,000 infants born before term, i.e. 26-36 weeks gestation. The neonatal mortality rate
was 315 per 1000 for infants who had a 5-minute Apgar score of 0-3, compared to 5 per
1000 in infants with a 5-minute Apgar score of 7-10. In term infants, the neonatal
mortality was 0.2 per 1000 if the 5-minute Apgar score was 7-10 vs. 244 per1000 if the
Apgar score was 0-3. These investigators concluded that the Apgar score, as a means of
evaluating the physical condition of the infant shortly after delivery, is still useful in
predicting survival during the neonatal period.
In summary, the Apgar score is useful to assess the condition of the infant at birth and
to predict survival through the immediate neonatal period. It should not be used alone
as evidence to assess neurologic damage and/or hypoxia. Another means to evaluate
the newborn is the umbilical artery blood gas pattern. An umbilical arterial blood pH <
7.2 is equal to acidemia. If the pCO2 is > 65 and the HCO3 is > 22, then respiratory
acidosis is present. Metabolic acidosis is present if the pCO2 is < 65 and the HCO3 is < 17
and a mixed pattern is if the pCO2 is > 65 and the HCO3 is 17.
Attempts have been made to relate the Apgar score to long-term outcomes caused by
antenatal events. In 1986, the American College of Obstetricians and Gynecologists, as
well as the American Academy of Pediatrics, issued a committee opinion on the use and
misuse of the Apgar score. The summary of this committee opinion states emphatically
that, “Apgar scores alone should not be used as evidence that neurologic damage is
caused by hypoxia or by inappropriate intrapartum management.” Importantly, there
are several factors that may affect the Apgar score and these include prematurity,
maternal medications and infection, such as chorioamnionitis.
It is recommended that blood gases be sent on all neonates with low Apgar scores to
distinguish acidemia from hypoxia or other causes that might result in low scores.
Teaching points:
Postpartum Care
Case study #1
A 22-year-old multigravida delivered her third healthy child without complications and is ready
for discharge from the hospital. She is breastfeeding, as she has with all of her children.
Although she is not currently married, she is in a stable relationship. She is interested in
permanent sterilization and wants to discuss this with you at her postpartum check-up. She
does not want anything for contraception at discharge since she is breastfeeding and is
“protected.”
Teaching points
1. Begin consideration of contraceptive options while the patient is in the
hospital
2. Unless women are breastfeeding every 3-4 hours around the clock, they may
be fertile as soon as 6 weeks post-partum
Case study #2
A 36-year-old married woman has just delivered her first child, a healthy baby girl weighing 7
lb. Her labor and delivery were uncomplicated. She and her husband, who had been trying to
have a baby for years, are thrilled about this child. She is discharged on postpartum day 2. Two
weeks after discharge, your nurse reports that the patient’s husband has called and is
concerned about his wife’s behavior. She is crying all of the time and last night she said, “she did
not love our daughter and wished she had not been born.” He thinks she “is probably just
exhausted” and wants something to help her sleep.
Teaching points
1. Mood disorders that persist for >10 days may represent post partum
depression and need to be addressed by the patient’s health care
provider.
TEACHING CASE 13
Lactation
Student Handout
Clinical Case:
A 22 year-old G1P1 comes to the office for an urgent office visit 4 days postpartum. She
states that she has not been feeling well, has had a fever at home, and has a tender
swollen area on her left breast. She has no problems with her right breast. Her
previous medical history is significant for severe depression for which she was taking
Lithium prior to pregnancy, but currently she is taking Zoloft. On examination, she is in
no distress but appears tired. Her temperature is 100.7C and BP is 130/70. On breast
examination, she has an erythematous tender 4 cm size area on the left breast. Her left
nipple is also tender and has some cracks. The right breast is normal. She really would
like to breast feed, because she has heard it is good for her baby. However it has been
causing her a lot of stress, and she feels he has not been having adequate milk
production. In addition, she is concerned about how it will affect her sleep and how
often she would have to do it especially at night. She also would like to resume taking
Lithium as her symptoms of severe depression are returning.
Discussion Questions:
4. How do you address this patient’s concern about inadequate milk production?
5. What do you tell her about how frequently and how long to breastfeed?
6. What do you tell her about the safety of using lithium while breastfeeding?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 10 Postpartum Care. Pages 128-
131.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition,2004; Chapter 9 Normal
Labor, Delivery, and Postpartum Care. Pages 125-127.
Lactation
Preceptor Handout
Knowledge of the physiology and function of the breast during lactation allows
appropriate counseling to the pregnant and postpartum woman.
The APGO Educational Objectives related to this topic are the following:
A. List the normal physiologic and anatomic changes of the breast during
pregnancy and the postpartum periods*
B. Recognize and treat common postpartum abnormalities of the breast*
C. List the reasons why breastfeeding should be encouraged*
D. Identify commonly used medications which are appropriate and inappropriate
to use while breastfeeding*
E. Counsel the lactating patient about commonly asked questions, such as
frequency, duration, inadequate production of milk, etc.
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Lactation
Preceptor Handout
Clinical Case:
A 22 year-old G1P1 comes to the office for an urgent office visit 4 days postpartum. She
states that she has not been feeling well, has had a fever at home, and has a tender
swollen area on her left breast. She has no problems with her right breast. Her
previous medical history is significant for severe depression for which she was taking
Lithium prior to pregnancy, but currently she is taking Zoloft. On examination, she is in
no distress but appears tired. Her temperature is 100.7C and BP is 130/70. On breast
examination, she has an erythematous tender 4 cm size area on the left breast. Her left
nipple is also tender and has some cracks. The right breast is normal. She really would
like to breast feed, because she has heard it is good for her baby. However it has been
causing her a lot of stress, and she feels he has not been having adequate milk
production. In addition, she is concerned about how it will affect her sleep and how
often she would have to do it especially at night. She also would like to resume taking
Lithium as her symptoms of severe depression are returning.
Discussion Questions:
This patient has mastitis: tender mass, fever, and systemic symptoms.
Engorgement is bilateral.
A plugged duct should not produce a fever or systemic symptoms.
Antibiotics for mastitis with coverage for staph aureus, B-hemolytic streptococci,
and haemophilus influenzae. Dicloxacillin if no penicillin allergy.
She should continue nursing from the affected breast. If she resumes the
Lithium, she should stop breastfeeding.
Warm compresses to the breast and a water based cream such as lanolin or A
and D ointment for the cracked nipple would be appropriate.
3. List the benefits of breastfeeding.
4. How do you address this patient’s concern about inadequate milk production?
You reassure her that colostrum is produced in the first 5 days and is gradually
replaced by milk on the third to sixth day of infant life. You further tell her that
colostrum protects the baby against infection and that the infant will usually get
adequate fluids and nutrition during this transition
5. What do you tell her about how frequently and how long to breastfeed?
There is no definite frequency or length of time that she should breast feed. She
should base this on infant demand.
6. What do you tell her about the safety of using lithium while breastfeeding?
You tell her that lithium is probably unsafe to use while breastfeeding.
It is very important to address her depression and assess her for any suicidal
ideation. Risks and benefits of depression versus breastfeeding need to be
carefully discussed with this patient.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 10 Postpartum Care. Pages 128-
131.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition,2004; Chapter 9 Normal
Labor, Delivery, and Postpartum Care. Pages 125-127.
UNIT TWO:
SECTION B
Ectopic Pregnancy
Student Handout
Clinical Case:
A 36-year-old G1P0010 female presents to your preceptor’s office with onset today of
light vaginal bleeding, which she feels is not her menstrual period, and mild right lower
quadrant pain which she rates as 2/10. The pain is intermittent and crampy, and is not
associated with urination. There is no nausea or vomiting. The patient’s last bowel
movement was yesterday and was normal in consistency without blood or black color.
Her past medical history shows no allergies, no medications, and two hospitalizations.
The first was eight years ago for lower abdominal pain which was thought to be due to
Pelvic Inflammatory Disease and which resolved with antibiotics. The second was for a
left ectopic pregnancy which required surgical removal of her left tube. Review of
Systems and Family History are unremarkable. Social History shows that she is
mutually monogamous with a male partner without birth control.
Physical Exam shows an anxious appearing female with a temperature of 99.2 degrees
orally, a BP of 105/62, and a pulse of 95. Examination of her abdomen shows normal
bowel sounds, no masses, organomegaly, distention, or rebound, and 2/10 right lower
quadrant pain. Pelvic examination reveals 2/10 right adnexal tenderness without
adnexal masses. Uterus is normal size. Rectal exam is negative with heme negative
stool.
Discussion Questions:
1. What is the differential diagnosis for this patient? Which specific symptoms and
signs does this patient have that are suspicious for an ectopic pregnancy?
2. What risk factors predispose patients to ectopic pregnancy and which of these
risk factors does this patient have?
3. Which is the most important test to do next in order to narrow down your
diagnosis?
4. If this patient’s pregnancy test is positive, what next tests could be helpful in
making a more definitive diagnosis?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 15 Ectopic Pregnancy. Pages 160-
170.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 25 Ectopic
Pregnancy. Pages 325-333.
Ectopic Pregnancy
Preceptor Handout
Ectopic pregnancy is a leading cause of maternal morbidity and mortality in the United
States. Early diagnosis and management may not only save lives, but may also preserve
future fertility.
The APGO Educational Objectives related to this topic are the following:
A. Develop a differential diagnosis for bleeding and abdominal pain in the first
trimester*
B. Identify risk factors for ectopic pregnancy*
C. Be able to evaluate a patient suspected of having an ectopic pregnancy*
D. Diagnose an ectopic pregnancy
E. Describe treatment options for patients with ectopic pregnancy
Clinical Case:
A 36-year-old G1P0010 female presents to your preceptor’s office with onset today of
light vaginal bleeding, which she feels is not her menstrual period, and mild right lower
quadrant pain which she rates as 2/10. The pain is intermittent and crampy, and is not
associated with urination. There is no nausea or vomiting. The patient’s last bowel
movement was yesterday and was normal in consistency without blood or black color.
Her past medical history shows no allergies, no medications, and two hospitalizations.
The first was eight years ago for lower abdominal pain which was thought to be due to
Pelvic Inflammatory Disease and which resolved with antibiotics. The second was for a
left ectopic pregnancy which required surgical removal of her left tube
Review of Systems and Family History are unremarkable. Social History shows that she
is mutually monogamous with a male partner without birth control.
Physical Exam shows an anxious appearing female with a temperature of 99.2 degrees
orally, a BP of 105/62, and a pulse of 95. Examination of her abdomen shows normal
bowel sounds, no masses, organomegaly, distention, or rebound, and 2/10 right lower
quadrant pain. Pelvic examination reveals 2/10 right adnexal tenderness without
adnexal masses. Uterus is normal size. Rectal exam is negative with heme negative
stool.
Discussion Questions:
1. What is the differential diagnosis for this patient? Which specific symptoms and
signs does this patient have that are suspicious for an ectopic pregnancy?
Differential Diagnosis:
-ectopic pregnancy
-incomplete, completed, or missed abortion
-threatened abortion
-ovarian cyst
-adnexal torsion
-pelvic inflammatory disease
-endometriosis
-appendicitis and GI etiologies
-urinary tract infections or stones
Symptoms or clinical presentation may include:
-abdominal pain(95-100%)*
-abnormal uterine bleeding(65-85%)*
-amenorrhea(75-95%).
Note that the LNMP was not given in the clinical case to see if the students ask
about this. You can tell them that the LNMP was 7 weeks ago.
-abdominal tenderness*(80-90%)
-adnexal tenderness* (75-90%)
-normal uterine size*( 70%)
-adnexal mass(30-50%)
However, ectopic pregnancies often have an atypical presentation and can have
extensive overlap with other abdominopelvic disorders.
The key learning point for students is that any sexually active women in the
reproductive age group who presents with pain, irregular bleeding, and/or
amenorrhea should have ectopic pregnancy as part of the initial differential
diagnosis. Pain is common but is not always the presenting symptom in ectopic
pregnancies.
2. What risk factors predispose patients to ectopic pregnancy and which of these risk
factors does this patient have (indicated with an *)?
3. Which is the most important test to do next in order to narrow down your
diagnosis?
HCG - Most important test. Sometimes skipped which can lead to mortality or
morbidity
4. If this patient’s pregnancy test is positive, what next tests could be helpful in
making a more definitive diagnosis?
STAT CBC (to check for anemia that may indicate intra-abdominal bleeding).
You could say that this patient had a Hematocrit of 37%.
You could say that this patient’s ultrasound showed no evidence of intra or
extra-uterine pregnancy and was normal.
Quantitative HCG
Initial to see if level is >1500mIU/ml so that lack of intrauterine pregnancy on
transvaginal ultrasound can lead to a high suspicion of extra-uterine pregnancy.
You could say that this patient’s HCG level was 830mIU/ml
This could lead to a discussion of whether to handle a patient like this with serial
repeat HCG levels, with methotrexate, or by surgery.
- Hemodynamically stable.
- No fetal heart beat seen outside of the uterus.
- Ectopic gestation that is not too big (usually <3.5cm).
- Cooperative patient who will be sure to return for follow-up and serial
HCGs and will report increased pain.
o Laparoscopy or Laparotomy with or without conservation of the fallopian
tube.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 15 Ectopic Pregnancy. Pages 160-
170.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 25 Ectopic
Pregnancy. Pages 325-333.
TEACHING CASE 15
Spontaneous Abortion
Student Handout
Clinical Case:
Lab data shows a serum HCG level of 6,500 mIU/ml and ultrasound shows a gestational
sac in the uterus with no fetus seen. The ovaries and tubes appear normal.
Discussion Questions:
4. Why does this patient have a fever and tenderness and what needs to be done
about it?
5. If this patient did not have fever and tenderness, what complications could she
develop?
6. If this patient was 6 weeks pregnant and had an HCG level of 700 mIU/ml and a
negative ultrasound, what would be your differential diagnosis if she had a small
amount of bleeding and no fever or tenderness?
8. For a patient with any type of abortion, what blood test is essential to do?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 14 Spontaneous Abortion. Pages
153-159.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 8 Antepartum
Care. Pages 85-89.
Spontaneous Abortion
Preceptor Handout
Bleeding is common in early pregnancy. A logical approach to its evaluation may not only
affect the outcome of the pregnancy, but also will help to reassure the patient.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
Lab data shows a serum HCG level of 6,500 mIU/ml and ultrasound shows a gestational
sac in the uterus with no fetus seen. The ovaries and tubes appear normal.
Discussion Questions:
-threatened abortion
-incomplete abortion
-complete abortion
-inevitable abortion
-missed abortion (subtype is blighted ovum)
-septic abortion
-recurrent abortion
-missed abortion
-septic abortion
4. Why does this patient have a fever and tenderness and what needs to be done about it?
6. If this patient was 6 weeks pregnant with no fever or tenderness, had an HCG level of
700 mIU/ml and a negative ultrasound with no evidence of a gestational sac, what
would be your differential diagnosis if she had a small amount of bleeding and no fever
or tenderness?
-threatened abortion
-incomplete abortion
-complete abortion
-missed abortion
Order serial HCGs since HCG level is too low for ultrasound to show an IUP
(which usually is seen on vaginal ultrasound at 1500-2000 mIU/ml HCG. If this
is a threatened abortion, the HCG level usually will increase at least 66% when
repeated in 48 hours. If it does not, a incomplete, complete, or missed abortion
is very likely, and a stable patient can either be followed down to a negative
quantitative HCG, have a D and C, or have a medical evacuation of the pregnancy.
8. For a patient with any type of abortion, what blood test is essential to do?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 14 Spontaneous Abortion. Pages
153-159.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 8 Antepartum
Care. Pages 85-89.
TEACHING CASE 16
Clinical Case:
A 30 year-old white female P0000 who is infected with human immunodeficiency virus
(HIV, diagnosed 4 years ago) presents to your office inquiring about future pregnancy.
She is recently married to a man who is not infected with HIV and they want to have a
child. She is concerned about whether her baby could be infected with HIV and whether
pregnancy could make her develop AIDS. She is asymptomatic and is taking no HIV
medications. Her pap smears have all been normal. Pertinent ROS: She has felt well, no
recent fevers, chills, cough, shortness of breath, abdominal pain, vaginal discharge,
night sweats, diarrhea, weight loss, or other symptoms. On examination she has normal
external genitalia, no vaginal discharge or cervical lesions, an anteverted uterus of
normal shape and size, nontender, with no adnexal masses palpable.
Laboratory tests: CD4+ lymphocyte count (per mm3) 489; HIV RNA (copies/ml) 6520.
Discussion Questions:
1. What are the major issues to discuss with a woman who is HIV+ and wants to have a
baby?
2. What are some of the risk factors for mother to child transmission (MTCT) of HIV?
3. What are the recommendations for treatment of HIV in pregnant women? How may
these differ from recommendations for non-pregnant adults?
4. Are there any antiretroviral drugs that should be avoided or administered in altered
doses in pregnant women with HIV?
References:
1. Public Health Service Task Force. Recommendations for use of antiretroviral drugs in pregnant
HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1
transmission in the United States and Safety and toxicity of individual antiretroviral agents in
pregnancy. February 24, 2005. Available at http://AIDSinfo.nih.gov. Accessed November 1, 2005.
2. Riley LE and Yawetz S. Case Records of the Massachusetts General Hospital: Case 32-2005: A 34-
year-old HIV-positive woman who desired to become pregnant. N Engl J Med 2005; 353:1725-32.
Medical and Surgical Conditions of Pregnancy
HIV in Pregnancy
Preceptor Handout
Medical and surgical conditions may alter the course of pregnancy and pregnancy may
have an impact on the management of these conditions.
Preceptor Handout
Clinical Case:
A 30 year-old white female P0000 who is infected with human immunodeficiency virus
(HIV) presents to your office inquiring about future pregnancy. She is recently married
to a man who is not infected with HIV and they want to have a child. She is concerned
about whether her baby could be infected with HIV and whether pregnancy could make
her develop AIDS.
History: The patient was diagnosed with HIV infection 4 years ago as part of a routine
annual visit at her gynecologist’s office. She believes that she acquired HIV through
heterosexual contact from a previous boyfriend. She has had no other known STIs. She
is asymptomatic and is taking no HIV medications. Her husband is HIV negative and
they use condoms regularly. Her pap smears have all been normal.
Pertinent ROS: She has felt well, no recent fevers, chills, cough, shortness of breath,
abdominal pain, vaginal discharge, night sweats, diarrhea, weight loss, or other
symptoms.
Laboratory tests: CD4+ lymphocyte count (per mm3) 489; HIV RNA (copies/ml) 6520.
Discussion Questions:
1. What are the major issues to discuss with a woman who is HIV+ and wants to have a
baby?
a. Management of HIV in a pregnant woman (or, does pregnancy alter the course of
HIV infection?). Answer: Fortunately, pregnancy does not appear to accelerate the
course of HIV infection. For the most part, pregnant women with HIV should be
treated in the same manner as non-pregnant adults with HIV (exceptions discussed
below).
b. Management of pregnancy in an HIV infected woman (or, what are the risks to
the fetus and are there ways to prevent mother to child transmission [MTCT] of
HIV?). Answer: The major risk to the fetus is MTCT of HIV. In the absence of
antiretroviral therapy, the MTCT rate for HIV is ~25%. With effective therapy, this
rate can be reduced to 1% or less. Additional risk factors for MTCT of HIV are
discussed below.
c. Safe sex practices (or, prevention of HIV infection for the HIV-negative partner in
discordant couples). Answer: Of course, abstinence or the regular use of condoms
are the best methods of prevention. The risk of transmission to the uninfected
husband in this case during each act of unprotected intercourse would be low (but
not eliminated) once the woman’s viral load becomes undetectable on therapy.
However, in the event of desired pregnancy such as in this case, artificial
insemination should be recommended.
a. Maternal disease status: CD4+ T-cell count, HIV viral load, AIDS (more
advanced disease is associated with an increased rate of MTCT).
b. Co-existing STIs (need to screen and treat).
c. Drug abuse (need to screen and offer treatment).
d. Labor-related factors: the majority of MTCT of HIV during pregnancy occurs
at the time of labor and delivery; major risk factors during this time include:
length of time membranes are ruptured (>4 hours associated with increased
risk), chorioamnionitis (infection associated with increased risk), fetal scalp
electrode (invasive monitoring associated with theoretically increased risk),
vaginal versus cesarean delivery (in the absence of antiretroviral therapy, in
the presence of ZDV monotherapy, or in the presence of HIV viral load >1000
on therapy women should be offered elective C/S at 38 weeks GA prior to
labor or ROM).
3. What are the recommendations for treatment of HIV in pregnant women? How may
these differ from recommendations for non-pregnant adults?
4. Are there any antiretroviral drugs that should be avoided or administered in altered
doses in pregnant women with HIV?
The field of HIV is a rapidly advancing one and the drug regimens available can be
complicated with multiple possible side effects. These factors emphasize the need for
consultation with a provider who is experienced in the care of HIV infected adults.
There is a web site that is updated regularly where providers can access current
guidelines as well as obtain assistance by phone and by e-mail
(http://AIDSinfo.nih.gov). Discussing all of the potential nuances of therapeutic options
and concerns in pregnancy is beyond the scope of this case. However, selected examples
follow: There are certain drugs that should be avoided or monitored differently in
pregnancy: 1) teratogenic effects (efavirenz or Sustiva®); 2) potential maternal or
neonatal mitochondrial toxicity (certain combinations of nucleoside reverse
transcriptase inhibitors, NRTIs); 3) potential maternal hepatic toxicity (nevirapine or
Viramune®); increased risk for glucose intolerance (protease inhibitors); and altered
pharmacokinetics (indinavir or Crixivan®).
Teaching Points:
Clinical: 1) antiretroviral therapy for HIV infected pregnant women (see discussion
question C) and 2) importance of preconception counseling for HIV-infected women
who wish to become pregnant.
Epidemiology: 1) transmission (timing and rates) of HIV from mother to fetus; 2) risk
factors for MTCT of HIV; and 3) safe sex practices.
References:
Public Health Service Task Force. Recommendations for use of antiretroviral drugs in pregnant HIV-1-
infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the
United States and Safety and toxicity of individual antiretroviral agents in pregnancy. February 24,
2005. Available at http://AIDSinfo.nih.gov . Accessed November 1, 2005.
Riley LE and Yawetz S. Case Records of the Massachusetts General Hospital: Case 32-2005: A 34-
year-old HIV-positive woman who desired to become pregnant. N Engl J Med 2005; 353:1725-32.
TEACHING CASE 17
Preeclampsia
Student Handout
Clinical Case:
An 18 year old G1P0 currently at 38 0/7 weeks presents for her routine prenatal visit.
She has had an uncomplicated pregnancy up to this point, with the exception of a late
onset of prenatal care and obesity (BMI of 35 kg/m2). She reports that during the past
week, she has noted some swelling of her hands and feet. She also has been feeling a bit
more fatigued and has had a headache on and off. She reports good fetal movement. She
has had some contractions on and off, but nothing persistent. Her blood pressure is
147/92 and her urine dip has 1+ protein/no ketones/no glucose. The fundal height
measures 36 cm, the fetus is cephalic with a heart rate of 144 bpm. On physical exam
you note that the patient has 3+ pre-tibial edema, and trace edema of her hands and
face. She has 2+ deep tendon reflexes and 2 beats of clonus. You review her blood
pressures up to this point and note that at the time of her first prenatal visit at 18
weeks, her blood pressure was 130/76 and she had no protein in her urine. However,
since that visit, her blood pressures seem to have been climbing higher with each visit.
Her last visit was one week ago, and she had a blood pressure of 138/88 with trace
protein in the urine and she has gained 5 pounds.
Discussion Questions:
1. What is the appropriate method for assessing blood pressure in the ambulatory
setting and what is considered a hypertensive blood pressure during pregnancy?
5. What types of maternal and fetal complications are associated with preclampsia-
eclampsia syndrome?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 17 Hypertension in Pregnancy.
Pages 188-196. Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004;
Chapter 15 Hypertensive Disorders of Pregnancy. Pages 197-207.
Preeclampsia
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
An 18 year old G1P0 currently at 38 0/7 weeks presents for her routine prenatal visit.
She has had an uncomplicated pregnancy up to this point, with the exception of a late
onset of prenatal care and obesity (BMI of 35 kg/m2). She reports that during the past
week, she has noted some swelling of her hands and feet. She also has been feeling a bit
more fatigued and has had a headache on and off. She reports good fetal movement. She
has had some contractions on and off, but nothing persistent. Her blood pressure is
147/92 and her urine dip has 1+ protein/no ketones/no glucose. The fundal height
measures 36 cm, the fetus is cephalic with a heart rate of 144 bpm. On physical exam
you note that the patient has 3+ pre-tibial edema, and trace edema of her hands and
face. She has 2+ deep tendon reflexes and 2 beats of clonus. You review her blood
pressures up to this point and note that at the time of her first prenatal visit at 18
weeks, her blood pressure was 130/76 and she had no protein in her urine. However,
since that visit, her blood pressures seem to have been climbing higher with each visit.
Her last visit was one week ago, and she had a blood pressure of 138/88 with trace
protein in the urine and she has gained 5 pounds.
Discussion Questions:
1. What is the appropriate method for assessing blood pressure in the ambulatory
setting and what is considered a hypertensive blood pressure during pregnancy?
Use an appropriate cuff size: 1.5 times upper arm circumference or a cuff
with a bladder that encircles 80% or more of the arm
Position the patient in the upright position
Allow the patient a 10 minute or longer rest period
No tobacco or caffeine 30 minutes preceding the measurement
Manual sphygmomanometer preferred
Symptoms:
Headache
Scotoma,
Pain in the right upper quadrant
Physical Findings:
Elevated blood pressure
Abnormal weight gain
Clonus
Generalized edema (e.g. hands and face in addition to lower extremity)
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 17 Hypertension in Pregnancy.
Pages 188-196.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 15
Hypertensive Disorders of Pregnancy. Pages 197-207.
CLINICAL CASE 18
Isoimmunization
At the conclusion of this exercise, the student will be able to demonstrate knowledge of
the following:
A 32-year-old woman, P1101, and her new husband present for prenatal care at 20
weeks’ gestation. Her past obstetric history is significant for a first child delivered at
term following an abruption. Her second child died of complications of prematurity
following in utero transfusions for Rh isoimmunization. Her initial prenatal labs this
pregnancy indicate her blood type as A negative and an antibody screen positive for
anti-D with a titer of 1:64. You discuss any additional evaluation needed, her risks in
this pregnancy, and the plan of management with her and her husband.
Teaching points:
1. What is Rh isoimmunization and what are the red cell antigens involved?
2. What are the risk factors for Rh isoimmunization?
3. What is the mechanism for RhoGAM prophylaxis against Rh disease?
4. What is the dose of RhoGAM?
5. What is the recommended schedule for RhoGAM administration?
6. Could this patient’s Rh isoimmunization have been prevented?
7. Is there any further blood work that should be obtained before you
counsel this patient on her risks in this pregnancy?
8. Discuss the management of the Rh-sensitized mother in an at-risk
pregnancy.
9. What are some ultrasound findings that may suggest Rh disease?
CLINICAL CASE 19
Multifetal Gestation
Ultrasound evaluation reveals normal cardiac activity for both twins; however, there is
a 28% difference in weights with Twin A (presenting, vertex) larger than Twin B
(upper, breech). There is normal amniotic fluid volume and a thin dividing membrane is
seen. An NST is performed and both twins have a reactive fetal heart rate pattern with
no decelerations. However, she is noted to be contracting every 3 minutes on the
tocodynamometer. Vaginal examination showed the cervix to be 3 cm dilated and 75%
effaced with the vertex of Twin A at –1 station. The membranes appeared to be intact.
She is admitted to labor and delivery and treated for preterm labor. Her contractions do
not slow down and she progresses to complete dilation. She is taken to the operating
room and Twin A delivers by spontaneous vaginal delivery without complications. Twin
B is delivered by total breech extraction and also does well. After delivery, she does well
and is discharged home after postpartum day #2.
Teaching points:
Fetal Death
At the conclusion of this exercise, the student will be able to:
Case study #1
A 30-year-old Hispanic woman Para 0020 has been followed in your practice with
insulin dependent diabetes and presents for a routine prenatal visit at 36 weeks’
gestation. She had a normal ultrasound at 20 weeks gestation with a normal fetal
anatomic survey. She reports no problems and good fetal movement. Her blood sugar
control has been reasonable. Her BP and urine dipstick were normal. Unfortunately, no
fetal heart tones were heard by Doppler and an ultrasound evaluation confirmed no
fetal cardiac activity. She is very upset and you spend time with her counseling her
regarding causes of fetal death and options for management.
Case study #2
A 26-year-old woman Para 0100 presents to your office for her first prenatal care visit.
She has no known medical problems. In her last pregnancy, she had an intrauterine
fetal demise at 28 weeks gestation. She reports that she began itching two weeks before
the baby died and her doctor did some blood tests and said everything was okay. At the
time of her delivery, she said the obstetrician taking care of her told her that the baby’s
umbilical cord was wrapped around its neck several times. She wants to discuss plans
for managing this pregnancy.
Teaching points:
Abnormal Labor
Clinical Case:
Charlene is a 31-year-old G1P0 attorney who has been treated in the infertility clinic for
several years to achieve this very desired pregnancy. Her prenatal care has been
uncomplicated. Her only problem has been heartburn for which she takes antacid
tablets with some relief. She comes to labor and delivery today at 40 6/7 wk. gestation.
She says the baby has been very active and she could not sleep well last night because of
discomfort. She states that she has been having contractions about every 5-7 minutes
for about 10 hours and she is exhausted. She wants the pregnancy to be over. She
denies leaking of fluid or vaginal bleeding, but did notice some bloody, sticky discharge
at about 3:00 am.
A vaginal exam reveals her cervix to be about 2cm dilated, 100% effaced, with a vertex
presentation at –3 station. Fetal heart tones are in the 140s with an external monitor.
Another external monitor confirms uterine contractions about every 5 minutes. Her
vital signs are stable and her physical examination is otherwise unremarkable.
Dipstick urinalysis reveals no protein, glucose or ketones. A blood clot to type and hold
is sent to the laboratory per hospital policy. A CBC is normal.
Charlene is admitted to labor and delivery where an IV line is placed. Two hours later,
there has been no change in the cervical exam and she asks for pain medicine. Narcotic
medication is ordered and she soon falls asleep. The fetal heart tones remain stable and
the contraction frequency has decreased.
Charlene is awakened about two hours after the narcotic dose by painful contractions
that appear on the monitor about every 3 minutes. A cervical exam is done revealing a
change to 5cm dilation, 100% effaced, and –2 station with some caput noted. The
membranes are artificially ruptured, revealing copious amounts of clear fluid; internal
fetal scalp and pressure monitors are placed. Charlene requests an epidural, and the
anesthetist is called.
The epidural functions well and the internal uterine pressure catheter show uterine
contractions every 7-10 minutes measuring 30-40 cmHg. The fetal heart tracing
remains reassuring. After another two hours, the cervix is unchanged and the station
has remained at –2. Oxytocin is started by intravenous pump. The uterine contractions
become more frequent, to every 2-4 minutes, and reach 50-60 cmHg. Her temperature
has climbed slightly, to 99.8 F. Two hours later the cervix is still 5 cm dilated and she
has a temperature of 101 F; the fetal heart rate is reassuring, but the baseline has
increased to the 160s. An operative delivery is planned.
Diagnosis:
Teaching points:
1. The Friedman curve is a tool to measure the rate of cervical change over time and
can be used to monitor the progress of labor in its latent and active phases. The
Friedman curve can be used to identify the patient who “falls off the curve” and
thus demonstrates an abnormality of labor. Such abnormalities can be due to a
lack of contractions, inadequate force of contractions, dystocia or cephalopelvic
disproportion. Some labor abnormalities, such as inadequate force or frequency
of contractions, can be remedied by the administration of oxytocin or other
contraction-inducing medications. Others, such as cephalopelvic disproportion,
require surgical intervention.
Clinical Case:
A 25-year-old G2P1 female at 32 weeks gestation is brought to labor and delivery by her
husband. About an hour before, she was watching television when she noted a sudden
gush of bright red blood vaginally. The bleeding was heavy and soaked through her
clothes, and she has continued to bleed since then. She denies any cramps or abdominal
pain. She says that her last sexual intercourse was a week ago. A review of her prenatal
chart finds nothing remarkable other than a borderline high blood pressure from her
first prenatal visit that has not required medication. There is no mention of bleeding
prior to this episode. She had an ultrasound to confirm pregnancy at 14 weeks, but none
since.
Physical examination reveals an extremely pale woman whose blood pressure is 98/60,
pulse 130, respirations 30, temperature 99 F. Her abdomen is soft without guarding or
rebound to palpation, and the uterus is nontender and firm, but not rigid. Fundal height
is 33cm. Fetal heart tones are in the 140s with good variability. The external monitor
reveals uterine irritability, but no discrete contractions are seen. There is a steady
stream of bright red blood coming from her vagina.
Discussion Questions:
1. What is your differential diagnosis for potential causes of bleeding for this
patient?
2. What steps would you take to evaluate this patient and determine the etiology of
the bleeding?
3. What signs and symptoms would help you differentiate the potential causes of
the bleeding?
4. What steps would you take to manage the low blood pressure and tachycardia
that the patient is displaying?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 20 Third-Trimester Bleeding. Pages
209-215.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 11 Obstetric
Hemorrhage and Puerperal Sepsis. Pages 146-150.
Third Trimester Bleeding
Preceptor Handout
Bleeding in the third trimester requires immediate patient evaluation. Thoughtful, prompt
evaluation and management is necessary to reduce the threat to the lives of the mother
and fetus.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
A 25-year-old G2P1 female at 32 weeks gestation is brought to labor and delivery by her
husband. About an hour before, she was watching television when she noted a sudden
gush of bright red blood vaginally. The bleeding was heavy and soaked through her
clothes, and she has continued to bleed since then. She denies any cramps or abdominal
pain. She says that her last sexual intercourse was a week ago. A review of her prenatal
chart finds nothing remarkable other than a borderline high blood pressure from her
first prenatal visit that has not required medication. There is no mention of bleeding
prior to this episode. She had an ultrasound to confirm pregnancy at 14 weeks, but none
since.
Physical examination reveals an extremely pale woman whose blood pressure is 98/60,
pulse 130, respirations 30, temperature 99 F. Her abdomen is soft without guarding or
rebound to palpation, and the uterus is nontender and firm, but not rigid. Fundal height
is 33cm. Fetal heart tones are in the 140s with good variability. The external monitor
reveals uterine irritability, but no discrete contractions are seen. There is a steady
stream of bright red blood coming from her vagina.
Discussion Questions:
1. What is your differential diagnosis for potential causes of bleeding for this patient?
Placental abruption
Placenta Previa
Vasa Previa
Genital lacerations/trauma (e.g. labial, vaginal or cervical)
Foreign body
Cervical cancer
Bloody show
2. What steps would you take to evaluate this patient and determine the etiology of
the bleeding?
3. What signs and symptoms would help you differentiate the potential causes of the
bleeding?
Placental abruption: Separation of the placenta from the uterine wall. It occurs
in about 20% of all third trimester bleeders and has a 25% recurrence risk in a
subsequent pregnancy. Risk factors for placental abruption include chronic
hypertension, cocaine use, abdominal trauma, sudden uterine compression (as
with rupture of membranes), and high parity. Physical findings include frequent
uterine contractions or hypertonicity, vaginal bleeding (sometimes
catastrophic), and fetal distress. Disseminated intravascular coagulation occurs
in 10% of cases, in 30% if the bleeding is severe. If the fetal heart tracing is
reassuring, expectant management and vaginal delivery may be considered. If
there are signs of maternal or fetal deterioration, an immediate cesarean
delivery is required. Perinatal mortality approaches 50% in severe cases.
Placenta previa: Occurs when placental tissue covers the cervical os. A central
or total placenta previa covers the os completely; as its name implies, a partial
placenta previa partially covers the os. In a marginal previa, the placental edge is
at the margin of the internal os while, with a low-lying placenta, the placenta
approaches the os, but is not at its edge. At 24 weeks, about 1 pregnancy in 20
will demonstrate ultrasound evidence of a placenta previa, while, at 40 weeks,
the incidence decreases to 1 in 200. Risk factors include prior cesarean delivery,
history of myomectomy, previous abortion, increased parity, multiple gestation,
advanced maternal age and smoking. Bleeding is usually painless and may occur
after intercourse. Management includes observation in labor and delivery, IV
access, continuous fetal monitoring and steroids for fetal lung maturation if
needed. Cesarean delivery is the method of choice with hysterectomy backup if
intraoperative bleeding cannot be controlled. Perinatal mortality can read 40%
Vasa previa: A rare condition where the fetal vessels of a velamentous cord
insertion cover the cervical os. The incidence is less than 1% of all pregnancies,
though it is increased in multiple gestations: up to 11% in twins and up to 95%
in triplets. The diagnosis is suggested by painless vaginal bleeding in the absence
of evidence of placenta previa or abruption. Treatment is delivery by cesarean
section.
Other causes: Causes of 3rd trimester bleeding such as cervicitis, cervical
erosions, trauma, cervical cancer, foreign body or even bloody show can usually
be differentiated on physical exam once the preceeding etiologies are ruled out.
4. What steps would you take to manage the low blood pressure and tachycardia that
the patient is displaying?
The most concerning feature of this presentation is the persistent bleeding and
vital signs suggestive of evolving shock related to acute blood. Tenets of
management should include:
Management of the patient with significant 3rd trimester hemorrhage, when the
fetus is mature, is hemodynamic stabilization and delivery. Vaginal delivery is
generally precluded in the setting of persistent hemodynamic instability.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 20 Third-Trimester Bleeding. Pages
209-215.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 11 Obstetric
Hemorrhage and Puerperal Sepsis. Pages 146-150.
TEACHING CASE 23
Preterm Labor
Student Handout
Clinical Case:
Your nurse tells you that the patient appears very anxious about this pregnancy and
that she has a lot of questions about why she had a premature baby in the first place.
She is concerned that she might have this type of complication with this current
pregnancy, but wishes that she could distinguish Braxton-Hicks contractions from true
labor better so that she can avoid coming to Labor & Delivery repeatedly like she did
last time.
Discussion Questions:
1. What are risk factors for preterm labor, and which if any does this patient have?
2. What characteristics distinguish Braxton-Hicks contractions from true labor
contractions?
3. What should you counsel the patient regarding the signs and symptoms of
preterm labor?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 22 Preterm Labor. Pages 221-227.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 13 Obstetric
Complications. Pages 167-175.
Preterm Labor
Preceptor Handout
Prematurity is the most common cause of neonatal mortality and morbidity. The
reduction of preterm births remains an important goal in obstetric care. Understanding
the causes and recognizing the symptoms of preterm labor provides the basis for
management decisions.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
Your nurse tells you that the patient appears very anxious about this pregnancy and
that she has a lot of questions about why she had a premature baby in the first place.
She is concerned that she might have this type of complication with this current
pregnancy, but wishes that she could distinguish Braxton-Hicks contractions from true
labor better so that she can avoid coming to Labor & Delivery repeatedly like she did
last time.
Discussion Questions:
1. What are risk factors for preterm labor, and which if any does this patient have?
3. What should you counsel the patient regarding the signs and symptoms of preterm
labor?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 22 Preterm Labor. Pages 221-227.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 13 Obstetric
Complications. Pages 167-175.
TEACHING CASE 24
Clinical Case:
A 26-year-old Hispanic woman, who is 31 weeks pregnant, presents to the labor unit
complaining of ruptured membranes. She notes that, for the last two days, she has had
increased vaginal discharge and some lower back pain. She reports a gush of fluid about
2 hours ago. The fluid ran down her leg and appeared clear and with no noticeable odor.
Her prior pregnancy was complicated by preterm labor and premature ruptured
membranes at 26 weeks gestation. The neonate’s course was complicated by
necrotizing enterocolitis, respiratory distress, and death at 28 days of life. Her past
obstetric history includes two prior preterm deliveries at 26 weeks gestation.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 23 Premature Rupture of
Membranes. Pages 228-232.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 13 Obstetric
Complications. Pages 172-174.
Premature Rupture of Membranes
Preceptor Handout
Rupture of membranes prior to labor is a problem for both term and preterm pregnancies.
Careful evaluation of this condition may improve fetal and maternal outcome.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
Discussion questions:
Teaching points:
The etiology of Preterm PROM is unknown, however, infection may play a
role
Complications of Preterm PROM include preterm delivery and all the risks
associated with prematurity, sepsis, cord prolapse. (Pulmonary hypoplasia
and skeletal anomalies are rare unless members rupture extremely early (<
22 weeks) and there is a concomitant prolonged latency period).
Management is dictated by the gestational age, fetal presentation, and
presence of chorioamnionitis.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 23 Premature Rupture of
Membranes. Pages 228-232.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 13 Obstetric
Complications. Pages 172-174.
CLINICAL CASE 25
Clinical Case:
A 27-year-old gravida 3 para 2 married female is admitted to the labor and delivery unit
in early labor. She has had an uncomplicated pregnancy similar to her other two
pregnancies, both of which delivered vaginally. Her last labor lasted 4 hours and the
infant’s birth weight was 3900 grams after an uncomplicated delivery.
At the time of admission to the labor and delivery unit, her physical examination reveals
a healthy appearing woman in moderate distress with contractions every 4-6 minutes,
described as 7 on a pain scale of 1-10, with 10 being most severe. Her weight is 165
pounds, blood pressure is 135/82, and fundal height is 37 cm. The estimated fetal
weight is around 4000 grams, the fetus is in the vertex presentation and her pelvic
examination reveals a normal-sized pelvis with cervix dilated to 5cm/80%
effacement/-1 station. Fetal heart rate is noted to be 120 beats per minute when the
external monitor is applied at 1600.
This patient appears to be having a normal labor at term. The fetal heart rate is normal
and the fetus is having accelerations of the fetal heart rate, also a reassuring finding.
Her contraction pattern appears normal, and we should expect a vaginal delivery in the
next few hours.
Two hours later, the nurse calls you to the labor suite to review the fetal heart tracing.
She expresses concern about the changed appearance of the fetal heart tracing and asks
for your opinion. What do you think is the most likely etiology for the appearance of the
fetal heart rate on the tracing below?
Discussion:
Postpartum Hemorrhage
Clinical Case:
Renee is a 33-year-old G3P2 patient who is scheduled for an elective repeat cesarean
delivery. She had a cesarean section two years ago for fetal intolerance to labor and has
been counseled about vaginal birth after cesarean section. She was ambivalent about
another surgery but, ultimately, decided for this since she also wanted a tubal ligation
and this could be done at the same time. She presents to labor and delivery at 38 wk.
gestation with spontaneous rupture of membranes an hour earlier. She is experiencing
intermittent, moderately painful contractions. She has called her husband at work, but
he has not yet arrived. She doesn’t want to proceed to a cesarean delivery without him
beside her.
Physical examination:
Per hospital protocol for previous cesarean section patients, a blood sample is sent for a
type and crossmatch, a CBC reveals WBC 8.8, hematocrit 37%, hemoglobin 9 and
platelets 280,000. A urine dipstick is negative for sugar, ketones or protein.
Diagnosis:
Postpartum hemorrhage
Assessment/plan
You order Pitocin to be placed in the IV solution and check her blood pressure, which is
100/65. You ask that Methergine .20 mg be given intramuscularly. This is done but the
uterus continues to bleed. You return her to the delivery room where bimanual
exploration of the uterus is done after her epidural is re-dosed. You discover a fragment
of retained placenta and remove it manually. There is no evidence of a dehiscence of the
prior uterine incision. Gentle curettage of the uterine cavity fails to produce further
tissue. Careful vaginal exam reveals no cervical or vaginal lacerations. The bleeding
slows markedly, but is still a trickle; the uterus is moderately firm. You ask that a dose
of PGF2a be given intramuscularly and this is done. Further uterine massage succeeds
in reducing the bleeding to scant amounts. You order a CBC to be done in 4 hours and
for her intravenous line to be maintained. She is taken, once again, to the recovery room
for observation. Her blood pressure is stable, she is afebrile and she is alert, oriented
and comfortable.
Teaching points:
2. Uterine atony is the most common cause and is, itself, caused by
precipitous labor; an overly distended uterus caused by such things as
macrosomia, multiple gestations or hydramnios; general anesthesia with
consequent uterine relaxation; amnionitis; oxytocin use in labor,
especially with prolonged inductions.
Postpartum Infection
Patient 1
Med: neg
Surgeries: none
No known drug allergies
Medications: Prenatal vitamins, Iron, Folate
Lab:
Patient 2
You are part of the obstetrical team caring for a 32-year-old primipara who has
presented with a term pregnancy and spontaneous rupture of membranes. The fluid is
clear, the baby is active and has a heart rate of 125, with good reactivity and variability.
The patient has had an unremarkable prenatal course. Pitocin induction is begun 24
hours after SROM.
Ten hours after beginning Pitocin induction, the patient is noted to be doing well with
her epidural. Her cervix is 7 cm dilated, 100% effaced. The fetus is in the vertex
position, seemingly OP, at -2 station. Her exam is unchanged 2 hours later despite Q 3
min. contractions that measure 60 mm Hg by an internal pressure catheter. She is
advised to have a cesarean section.
She delivers a 9 1b. 2 oz. boy, Apgars 7 and 9, by low transverse cesarean section. The
procedure is uncomplicated. Blood loss is estimated at 500 cc. She receives 2 grams of
a cephalosporin for prophylaxis after the umbilical cord is clamped and 20 units of
Pitocin after the placenta is removed.
On the second full day postpartum/post op, she complains of generally not feeling well.
She feels tired and achy, and wonders if she has a fever. She has no appetite and has not
yet passed flatus. The nurse reports that the patient’s pulse is 88, BP 110/70, and
temperature 38.5 °C. Lower abdominal and uterine tenderness are the only positive
findings on exam.
Lab:
19,000 WBC, Hct 34, VA few epithelial cells, 1-5 WBC’s, rare bacteria
Assessment/Plan:
Postpartum endometritis
Parenteral antibiotics
Discussion:
The route of delivery that is vaginal vs. cesarean section is the single most important
risk factors. The incidence of endometritis following vaginal delivery rarely exceeds 2 –
3%; however, after cesarean section frequency ranges from 10% in low risk patients
who have received prophylactic antibiotics to as high as 95% in a high risk population
without prophylactic antibiotics. In the later group, i.e. cesarean section, if the
membranes have been ruptured for a prolonged period of time (> than 6 hours) and the
patient has had prolonged labor, then the likelihood of endometritis is markedly
increased. There are few data to support a direct increase in endometritis following the
use of electronic fetal monitoring or on the number of vaginal examinations. It is true
and related that with slow progress of labor there are more vaginal exams performed.
The most common reported clinical signs and symptoms of postpartum endometritis
include fever, leukocytosis, lower abdominal pain, uterine tenderness and foul-smelling
vaginal discharge. Clearly, the most important sign and symptom is that of fever. This
diagnosis is based on clinical findings alone and there has been no laboratory and/or
culture techniques used to increase the likelihood of this diagnosis.
Teaching points:
Clinical Case:
Ms. Davis is a 22-year-old G3P2Ab1 African American reports that besides being
overwhelmed by having a newborn baby, her 2 ½-year-old daughter recently
experienced a severe illness. Since that time, she intermittently has thoughts about
hurting herself and her children. Her mother is aware of her concerns and is currently
caring for the children.
During her visit, Ms. Davis describes feeling depressed, sleep deprived, guilty and
hopeless. She also states that she has had crying spells and a decreased appetite for the
last two months. She can go “a day or two” without being hungry or eating, and she
reports feeling like her children “would be better off without me or if they weren’t
here.” She has made no plans to act on these feelings, although she notes that these
feelings have increased in frequency over the past two months.
Ms. Davis states that sometimes when she hears the newborn cry, she thinks she hears a
voice in her head telling her to “just shake him until he stops crying.” When she has
these kinds of thoughts, she says, she calls her mother or husband or reads the Bible
until these thoughts and feelings subside. She worries, however, that one day she will
not be placated by these means alone. She admits that occasionally she acts on impulse.
Ms. Davis notes that her sister has depression and is treated with fluoxetine.
She is a stay-at-home mom who has been married five years. Her pregnancy was
uncomplicated and she had a normal vaginal delivery at term. She initially tried to
breast feed, but stopped after 3 days due to “sore nipples.”
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 10 Postpartum Care. Pages 129-
131.
Anxiety and Depression
Preceptor Handout
Pregnancy, as with any significant life event, may be accompanied by anxiety and
depression. Recognition of psychological disturbance is essential for early intervention.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
Ms. Davis is a 22-year-old G3P2Ab1 African American reports that besides being
overwhelmed by having a newborn baby, her 2 ½-year-old daughter recently
experienced a severe illness. Since that time, she intermittently has thoughts about
hurting herself and her children. Her mother is aware of her concerns and is currently
caring for the children.
During her visit, Ms. Davis describes feeling depressed, sleep deprived, guilty and
hopeless. She also states that she has had crying spells and a decreased appetite for the
last two months. She can go “a day or two” without being hungry or eating, and she
reports feeling like her children “would be better off without me or if they weren’t
here.” She has made no plans to act on these feelings, although she notes that these
feelings have increased in frequency over the past two months.
Ms. Davis states that sometimes when she hears the newborn cry, she thinks she hears a
voice in her head telling her to “just shake him until he stops crying.” When she has
these kinds of thoughts, she says, she calls her mother or husband or reads the Bible
until these thoughts and feelings subside. She worries, however, that one day she will
not be placated by these means alone. She admits that occasionally she acts on impulse.
Ms. Davis notes that her sister has depression and is treated with fluoxetine.
She is a stay-at-home mom who has been married five years. Her pregnancy was
uncomplicated and she had a normal vaginal delivery at term. She initially tried to
breast feed, but stopped after 3 days due to “sore nipples.”
Discussion Questions:
2. How do her symptoms compare with other women at this postpartum stage?
3. If you were to develop a treatment protocol for Ms. Davis, what would it comprise?
Use drugs such as Sertraline and Amitriptyline, since they are safe in lactating
women. One study suggests that several commonly prescribed and efficacious
agents can be safely given to the breast feeding mother suffering from
postpartum depression (PPD). Quantifiable amounts of the maternal medication
are not found in the infant’s blood. Based on this guideline, the authors
recommend using the following drugs in cases where the mother desires to
continue breast feeding: Amitriptyline, Nortriptyline, Desipramine,
Clomipramine or Sertraline. SSRIs preferred as tricyclic antidepressants have
more side effects and an overdose could be lethal.
Fluoxetine (Prozac) is not a good drug for this disorder. Fluoxetine, although a
very useful and popular antidepressant, has been found to permeate breast milk
to levels approximately 20-25% of maternal plasma. This has prompted the drug
manufacturer to advise against the use of this product in the breast feeding
woman. In a case report, severe colic, fussiness and crying were identified in a
parturient taking fluoxetine. It has also been associated with reduced growth
that may be of clinical importance in situations in which the infant weight gain is
already of concern. Shorter acting SSRIs, such as Paroxetine, preferred.
Hormonal therapy is a newer option aimed at the potential causes of PPD. Some
investigators believe that mood disorders postpartum are precipitated by
changes in estrogen levels. The hypothalamic-pituitary-adrenal axis is greatly
suppressed directly after childbirth, and some researchers in the field of
endocrinology believe that estrogen will normalize CRH secretion and reactivate
the H-P-A axis to mitigate depressive symptoms in the postpartum woman.
5. Is a referral or consult needed for Ms. Davis and what would be your justification?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 10 Postpartum Care. Pages 129-
131.
TEACHING CASE 29
Postterm Pregnancy
Student Handout
Clinical Case:
A 35-year-old, G1P0, woman presents to your office for a routine prenatal exam. She is
5 days past her due date that was determined by her last menstrual period and a
second trimester ultrasound. While reviewing her chart, you note that she has gained
32 pounds during this uncomplicated pregnancy. Today’s exam reveals a weight gain of
1/2 pound since last week’s visit. Her BP is 110/65. She has no glycosuria or
proteinuria. The fundal height measures 38 cm and fetal heart tones are auscultated at
120 bpm in the left lower quadrant. The fetus has cephalic presentation and an
estimated weight of 8 lbs.
Just before you go into the room, your nurse pulls you to the side, and tells you, “She has
a lot questions!” Once you walk into the room, the patient expresses her
disappointment that she has not had the baby yet. She assumed that she will be having
the baby on her due date. She asks you about potential harm to her and the baby from
going past her due date, and she would like to know her options.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 21 Postterm Pregnancy. Pages 216-
220.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 13 Obstetric
Complications. Pages 179-182.
Postterm Pregnancy
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
A 35-year-old, G1P0, woman presents to your office for a routine prenatal exam. She is
5 days past her due date that was determined by her last menstrual period and a
second trimester ultrasound. While reviewing her chart, you note that she has gained
32 pounds during this uncomplicated pregnancy. Today’s exam reveals a weight gain of
1/2 pound since last week’s visit. Her BP is 110/65. She has no glycosuria or
proteinuria. The fundal height measures 38 cm and fetal heart tones are auscultated at
120 bpm in the left lower quadrant. The fetus has cephalic presentation and an
estimated weight of 8 lbs.
Just before you go into the room, your nurse pulls you to the side, and tells you, “She has
a lot questions!” Once you walk into the room, the patient expresses her
disappointment that she has not had the baby yet. She assumed that she will be having
the baby on her due date. She asks you about potential harm to her and the baby from
going past her due date, and she would like to know her options.
Discussion Questions:
1. Define “term”, “postdates”, and “postterm” pregnancy and the prevalence of each.
Factor Discussion
Inaccurate or unknown dates Most common cause; high association with and
major risk factor of late or no prenatal care
Altered estrogen:progesterone
ratio
Antenatal Concerns:
Macrosomia – estimated prevalence of 25% in prolonged pregnancy
Postmaturity syndrome – (see discussion below)
Perinatal death – rate increases steadily after 37 weeks, approaching 1 in
300 at 42 weeks.
Intrapartum Concerns:
Labor dystocia
Infant Birth trauma
Maternal perineal trauma
Cesarean delivery
Postpartum hemorrhage
Meconium passage
Neonatal Concerns:
Meconium aspiration syndrome
Hypoglycemia
Hyperbilirubinemia
1. What are the features of fetal postmaturity syndrome?
Option 1:
Induce labor
Option 2:
Expectant management in anticipation of spontaneous labor
Fetal surveillance
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 21 Postterm Pregnancy. Pages 216-
220.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 13 Obstetric
Complications. Pages 179-182.
CLINICAL CASE 30
Cherie is a 26-year-old G2PO female who presents to your office for her first prenatal
visit. She states that the pregnancy has been uncomplicated, except for one episode of
the flu. History reveals that her LMP was 35 weeks ago. Her periods are irregular. She
smokes 2 packs of cigarettes a day and has gained 8 lbs. during this pregnancy.
Physical Exam:
Prenatal Lab:
Toxoplasmosis - <1:16
Herpes - <0.25
Rubella - Immune
CMV - .29
CBC - Hgb -10.1 gm/dl
WBC - 8.6
VDRL = non-reactive
Blood Type - 0+
Antibody Screen - negative
Estimated fetal weight = 1700 308 grams, less than the 10th percentile at 34.9 weeks
Fetal Organ Imaging
Kidneys: +
Bladder: +
Stomach: +
Spine: Appears grossly normal
Cardiac motion: + (normal four chamber view)
Fetal Breathing: + Limb motion: +
S/D ratio = 2.66 (average of 3 measurements). This is within normal limits for this
gestational age.
Clear views of the cerebellum and cord insertion are not possible today due to fetal
positions.
1. What do you tell the patient about her diagnosis, causes and treatment options?
3. Now what?
UNIT TWO:
SECTION C
OBSTETRICS - Procedures
Obstetric Procedures
Student Handout
Clinical Case:
A 26 year old, G3P2002 presents to Labor and Delivery with a complaint of frequent,
painful uterine contractions and leaking of fluid. She has been getting prenatal care
through your clinic and review of her records shows her to be 36 6/7 weeks with a
spontaneous dichorionic/diamniotic twin pregnancy. She has had a completely
uncomplicated pregnancy to date, with the exception of obesity. She is 5’ 4” tall and
weighs 220 pounds, giving her a BMI of 37.8 kg/m2. Your evaluation reveals the patient
to be 8 cm dilated, fully effaced, and +1 station. Although, the membranes are ruptured,
you are unsure of the presenting part. The fetal heart rate tracings for both twins are
reassuring. During your evaluation, the patient repeatedly tells you that she really
wants to deliver these twins vaginally because she delivered both of her prior babies
vaginally, and doesn’t want to be slowed down by the recovery from a cesarean.
Discussion Questions:
1. Is this patient a candidate for a vaginal delivery of her twins? What additional
information do you need to make that decision?
2. You confirm that the patient is indeed a good candidate for vaginal delivery. What are
the complications that this patient may encounter during her delivery?
3. What pre-delivery preparations can you make to minimize these risks for the patient?
4. The patient achieves the 2nd stage of labor and progresses well to deliver the first infant
without complication. You perform an assessment for the presentation of the 2nd twin
and find it to be breech. What are your options for delivering the 2nd twin?
5. You proceed with attempting vaginal delivery of the 2nd twin. While waiting for the 2nd
fetus to progress in labor, you notice the onset of heavy vaginal bleeding. The fetal heart
rate tracing begins to deteriorate and you perform a cesarean delivery. What measures
can you take intra-operatively to prevent complications from the cesarean?
6. You complete the cesarean successfully, but note that the patient had an estimated
blood loss of 1500 cc probably due to an abruption. What measures can you take post-
operatively assess for and diagnose complications?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 18 Multifetal Gestation. Pages 197-
201 & Chapter 24 Obstetric Procedures. Pages 233-238.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 14 Multifetal
Gestation and Malpresentation. Pages 183-196 & Chapter 18 Obstetric Procedures. Pages 247-255.
Obstetric Procedures
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
A 26 year old, G3P2002 presents to Labor and Delivery with a complaint of frequent,
painful uterine contractions and leaking of fluid. She has been getting prenatal care
through your clinic and review of her records shows her to be 36 6/7 weeks with a
spontaneous dichorionic/diamniotic twin pregnancy. She has had a completely
uncomplicated pregnancy to date, with the exception of obesity. She is 5’ 4” tall and
weighs 220 pounds, giving her a BMI of 37.8 kg/m2. Your evaluation reveals the patient
to be 8 cm dilated, fully effaced, and +1 station. Although, the membranes are ruptured,
you are unsure of the presenting part. The fetal heart rate tracings for both twins are
reassuring. During your evaluation, the patient repeatedly tells you that she really
wants to deliver these twins vaginally because she delivered both of her prior babies
vaginally, and doesn’t want to be slowed down by the recovery from a cesarean.
Discussion Questions:
1. Is this patient a candidate for a vaginal delivery of her twins? What additional
information do you need to appropriately counsel this patient?
2. You confirm that the patient is indeed a good candidate for vaginal delivery. What
are the complications that this patient may encounter during her delivery?
Adapted from Hacker & Moore, 4th Edition, Chapter 14, page 187
4. The patient achieves the 2nd stage of labor and progresses well to deliver the first
infant without complication. You perform an assessment for the presentation of the
2nd twin and find it to be transverse. What are your options for delivering the 2 nd
twin?
5. The fetus spontaneously converts to a cephalic presentation and you proceed with
attempting vaginal delivery of the 2nd twin. While waiting for the 2nd fetus to
progress in labor, you notice the onset of heavy vaginal bleeding. The fetal heart
rate tracing begins to deteriorate and you perform a cesarean delivery. What
measures can you take intra-operatively to prevent potential complications of the
cesarean?
Intra-operative antibiotics for endometritis prophylaxis
IV oxytocin for uterine atony prophylaxis
Have additional uterotonics available for treatment of persistent atony
6. You complete the cesarean successfully, but note that the patient had an estimated
blood loss of 1500 cc probably due to an abruption. What measures can you take
post-operatively to assess for and diagnose complications?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 18 Multifetal Gestation. Pages 197-
201 & Chapter 24 Obstetric Procedures. Pages 233-238.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 14 Multifetal
Gestation and Malpresentation. Pages 183-196 & Chapter 18 Obstetric Procedures. Pages 247-255.
UNIT THREE:
SECTION A
Clinical Case:
Discussion questions:
6. What physical exam and studies are required for prescribing hormonal
contraceptives?
7. What contraceptives should the patient be counseled about and what are the
advantages and disadvantages of each method?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 25 Contraception. Pages 241-257.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 27 Family
Planning: Contraception, Sterilization, and Abortion. Pages 341-351.
The APGO Educational Objectives related to this topic are the following:
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Contraception and Sterilization
Preceptor Handout
Clinical Case:
Discussion Questions:
o Sexual history
Onset of sexual activity
Number of partners since onset
History of STDs
o Medical history – contraindications to estrogen-containing hormonal
contraceptives
Migraines with aura
DVT
Hypertension
Smoking age > 35
o Menstrual history
LMP (pregnancy)
Irregular menses
2. What physical exam and studies are required for prescribing hormonal
contraceptives?
a. Pap and pelvic exam have typically been “bundled services,” i.e., these
exams are required to prescribe contraceptives. There is no rationale for
this bundling.
b. Paps should be initiated 3 years after onset of sexual activity—this
patient became sexually active 2 years ago
c. STD screening for a sexually active teenager should include chlamydia
which may be tested with urine. Other STDs should be screened for
based on individual risk assessment.
d. A blood pressure should be obtained in patients who desire estrogen-
containing contraceptives to R/O hypertension, rare in this age group, but
easy to obtain, non-sensitive and low cost.
Condoms
i. Advantages
b. STD protection
ii. Disadvantages
b. Need to use every time
c. Decreased sensation
Depo-provera
i. Advantages
b. 4 shots per year
c. Highly effective
ii. Disadvantages
b. Irregular bleeding
c. Weight gain
d. No STD protection
IUD
i. Advantages
b. Longterm contraception with single act motivation
c. Highly effective
d. High continuation
ii. Disadvantages
b. No STD protection
Plan B
i. Advantages
b. Backs up regular birth control
c. Useful for accidents – condom breaking, discontinued
methods
ii. Disadvantages
b. Not as effective as regular methods
c. May be difficult to obtain
4. When/how to start the contraceptive method?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 25 Contraception. Pages 241-257.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 27 Family
Planning: Contraception, Sterilization, and Abortion. Pages 341-351.
Abortion
Student Handout
Clinical Case:
Discussion questions:
1. What is options counseling and how would you counsel this patient about her
options?
3. Can the patient consent for termination herself or must she have parental
consent since she is a minor?
4. What types of abortion is this patient eligible for, given her gestational age of 8
weeks?
9. How should this patient be counseled and managed regarding STD prevention?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 2 Ethics in Obstetrics and
Gynecology. Pages 28-29 & Chapter 14 Abortion. Pages 158-159.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 27 Family
Planning: Contraception, Sterilization, and Abortion. Pages 350-351.
Abortion
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
Discussion questions:
1. What is options counseling and how would you counsel this patient about her
options?
3. Can the patient consent for termination herself or must she have parental consent
since she is a minor?
4. What types of abortion is this patient eligible for, given her gestational age of 8
weeks?
9. How should this patient be counseled and managed regarding STD prevention?
- She should be counseled about condom use and STD prevention. Self-
esteem/education counseling: An evaluation of this patient’s social
situation and the reasons for her having a sexual relationship with a 21-
year old should be explored. She should be offered an STD screen,
including gonorrhea and chlamydia cultures and blood tests for HIV,
syphilis and hepatitis B.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 2 Ethics in Obstetrics and
Gynecology. Pages 28-29 & Chapter 14 Abortion. Pages 158-159.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 27 Family
Planning: Contraception, Sterilization, and Abortion. Pages 350-351.
TEACHING CASE 34
Clinical Case:
A 20-year-old female college student G2P2 comes to see you because of a persistent
vaginal discharge and also seeking contraceptive advice. She and her boyfriend have
been sexually active for 6 months. They use condoms “most of the time”, but she is
interested in using something with a lower failure rate for birth control. She has
regular menses and no significant past medical or gynecologic history. She describes
the discharge as yellowish and also notes mild vulvar irritation. On physical exam, she
has normal external female genitalia without lesions or erythema, a gray/yellow
discharge on the vaginal walls and pooled in the posterior fornix. Her cervix is grossly
normal but bleeds easily with manipulation. The bimanual exam is unremarkable.
Laboratory testing reveals Vaginal fluid pH = 7 and vaginal wet prep positive for mobile
flagellated organisms.
Discussion Questions:
4. What are the additional issues you would want to discuss with this patient?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 27 Vulvitis and Vaginitis. Pages 265-
272.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 23 Pelvic
Infections. Pages 296-308.
Vulvar and Vaginal Disease
Preceptor Handout
Vaginal and vulvar symptoms are frequent patient concerns. In order to provide
appropriate care, the physician must understand the common etiologies of these
problems, as well as appropriate diagnostic and management options.
The APGO Educational Objectives related to this topic are the following:
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Vulvar and Vaginal Disease
Preceptor Handout
Clinical Case:
A 20-year-old female college student G2P2 comes to see you because of a persistent
vaginal discharge and also seeking contraceptive advice. She and her boyfriend have
been sexually active for 6 months. They use condoms “most of the time,” but she is
interested in using something with a lower failure rate for birth control. She has regular
menses and no significant past medical or gynecologic history. She describes the
discharge as yellowish and also notes mild vulvar irritation. On physical exam, she has
normal external female genitalia without lesions or erythema, a gray/yellow discharge
on the vaginal walls and pooled in the posterior fornix . Her cervix is grossly normal but
bleeds easily with manipulation. The bimanual exam is unremarkable.
Laboratory testing reveals Vaginal fluid pH = 7 and vaginal wet prep positive for mobile
flagellated organisms.
Discussion Questions:
4. What are the additional issues you would want to discuss with this patient?
STI protection
contraception
5. What contraceptive options would be appropriate for this patient?
A variety of contraceptive methods may be appropriate to achieve
effective contraception in this patient including oral contraceptives,
patches, ring or injection.
She is not a good candidate for sterilization (due to age), IUD (due to STI
history) and condom/diaphragm/spermicide (due to non-compliance).
The effectiveness, precautions, contraindications and method
administration should be discussed with the patient so that she can make
an informed choice.
It is important for the student to realize that a patient may have more
than one clinical issue to discuss.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 27 Vulvitis and Vaginitis. Pages 265-
272.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 23 Pelvic
Infections. Pages 296-308.
TEACHING CASE 35
Clinical Case:
A 16-year-old G1P1, LMP one week ago, presents with a one-week history of severe
lower abdominal pain. Pain is constant, bilateral and accompanied by fever and chills.
She has had some nausea and several episodes of vomiting. She has been sexually active
for 3 years and has had unprotected intercourse with several partners. She denies
irregular bleeding, dysmenorrhea or dyspareunia. Past medical history is negative
except for childhood illness. Past surgical history is remarkable for tonsillectomy as a
child and an uncomplicated vaginal delivery one year ago.
Physical exam reveals an ill appearing 16-year-old who is afebrile and has a pulse of 94
bpm, BP 124/82 and a respiratory rate 22 breaths/minute. On examination of the
abdomen, there is bilateral lower abdominal tenderness and the abdomen is slightly
distended with rebound, negative psoas and Murphy’s signs. Pelvic exam reveals the
BUS negative and the vagina pink, moist. There is a purulent discharge from the cervical
os and the cervix appears indurated. The uterus is in the midline position and is soft
and tender to palpation. There is bilateral adnexal fullness and moderate tenderness.
Laboratory evaluation includes positive GC, negative RPR and WBC 17.6 with a left shift.
Urinalysis is remarkable for few WBC’s, no bacteria, 3+ ketones and negative urine HCG.
Discussion questions:
3. What are the most likely organisms responsible for this condition?
4. What are the common presenting signs and symptoms for this condition?
6. What criteria will you use to determine inpatient vs. outpatient treatment?
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 28 Sexually Transmitted Diseases.
Pages 273-287.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 23 Pelvic
Infections. Pages 296-308.
Centers for Disease Control and Prevention. Sexually Transmitted Disease Treatment Guideline 2006.
www.cdc.gov/std/treatment/
Sexually Transmitted Infections
Preceptor Handout
To prevent sexually transmitted infections and urinary tract infections, the physician
should understand their basic epidemiology, diagnosis and management. The potential
impact of acute or chronic salpingitis is significant. Early recognition and optimal
management may help prevent the long-term sequelae of tubal disease.
The APGO Educational Objectives related to this topic are the following:
I. Counsel the patient about the public health concerns for STI’s,
including screening programs, costs, prevention and
immunizations, and partner evaluation and treatment
Clinical Case:
A 16-year-old G1P1, LMP one week ago, presents with a one-week history of severe
lower abdominal pain. Pain is constant, bilateral and accompanied by fever and chills.
She has had some nausea and several episodes of vomiting. She has been sexually active
for 3 years and has had unprotected intercourse with several partners. She denies
irregular bleeding, dysmenorrhea or dyspareunia. Past medical history is negative
except for childhood illness. Past surgical history is remarkable for tonsillectomy as a
child and an uncomplicated vaginal delivery one year ago.
Physical exam reveals an ill appearing 16-year-old who is afebrile and has a pulse of 94
bpm, BP 124/82 and a respiratory rate 22 breaths/minute. On examination of the
abdomen, there is bilateral lower abdominal tenderness and the abdomen is slightly
distended with rebound, negative psoas and Murphy’s signs. Pelvic exam reveals the
BUS negative and the vagina pink, moist. There is a purulent discharge from the cervical
os and the cervix appears indurated. The uterus is in the midline position and is soft
and tender to palpation. There is bilateral adnexal fullness and moderate tenderness.
Laboratory evaluation includes positive GC, negative RPR and WBC 17.6 with a left shift.
Urinalysis is remarkable for few WBC’s, no bacteria, 3+ ketones and negative urine HCG.
Discussion questions:
3. What are the most likely organisms responsible for this condition?
Likely pathogens include N gonorrhoeae, C trachomatis, anaerobes, gram-
negative bacteria and streptococci. All pelvic inflammatory disease (PID)
treatment regimens must therefore provide broad-spectrum coverage.
4. What are the common presenting signs and symptoms for this condition?
The most common presenting complaint of women with PID is lower
abdominal pain.
Associated symptoms include vaginal discharge, irregular bleeding,
dysmenorrhea, dyspareunia, dysuria, nausea, vomiting and fever.
Pelvic pain, fever and vaginal discharge are the most common findings if PID
is secondary to gonococcal infection. Patients may be asymptomatic if
chlamydia is the causative organism. Women who have gonococcal infection
have evidence of more acute inflammation (peritoneal signs, fever,
leukocytosis) than those who have nongonococcal infection because of the
endotoxin produced by N gonorrhoeae.
The clinical criteria necessary for the diagnosis of PID include:
o Abdominal tenderness +/- rebound
o Adnexal tenderness
o Cervical motion tenderness
o Plus one or more of the following: Gram stain of endocervix positive
for Gram negative intracellular diplococci, temperature >38 degrees C,
WBC>10,000, pus on culdocentesis or laparoscopy, pelvic abscess on
bimanual exam or ultrasound
Most women with acute PID present during the first half of the menstrual
cycle. Presentation later in the cycle indicates an infection of longer duration
and increases the likelihood of a tuboovarian abscess (TOA).
Atypical presentations of PID are common and complicate the differential
diagnosis. For example, the symptoms of Fitz-Hugh-Curtis syndrome may
mimic hepatitis or cholecystitis.
6. What criteria will you use to determine inpatient vs. outpatient treatment?
Although broad-spectrum antibiotic coverage results in symptomatic
improvement in most patients, the risk of long-term sequelae remains
high.
Adolescents are at high risk for future reproductive complications due to
non-compliance. The CDC recommends serious consideration of
hospitalization for adolescents with PID.
Hospitalization is recommended if compliance is unpredictable, if the
diagnosis is uncertain, or if pelvic abscess is suspected.
Hospitalization is essential if the patient is pregnant, has HIV infection, is
too ill to tolerate (if vomiting, for example) or has failed to respond to
outpatient therapy within 48 hours.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 28 Sexually Transmitted Diseases.
Pages 273-287.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 23 Pelvic
Infections. Pages 296-308.
Centers for Disease Control and Prevention. Sexually Transmitted Disease Treatment Guideline 2006.
www.cdc.gov/std/treatment/
TEACHING CASE 36
Clinical Case:
A 75-year-old woman G5P5 presents for an annual exam and reports having a “fullness”
in the vaginal area. The symptom is more noticeable when she is standing for a long
period of time. She does not complain of urinary or fecal incontinence. She has no other
urinary or gastrointestinal symptoms. There has been no vaginal bleeding. Her past
medical history is significant for well-controlled hypertension and chronic bronchitis.
She has never had surgery.
Pelvic exam reveals normal appearing external genitalia except for generalized atrophic
changes. The vagina and cervix are without lesions. A cystocele and rectocele are noted.
The cervix descends to the introitus with the patient in an upright position. Uterus is
normal size. Right and left ovaries are not palpable. No rectal masses are noted. Rectal
sphincter tone is slightly decreased. The patient prefers non-surgical treatment. A
pessary is placed and you prescribe vaginal estrogen to address atrophic changes.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 29 Pelvic Relaxation, Urinary
Incontinence, and Urinary Tract Infection. Pages 288-298.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 24
Genitourinary Dysfunction: Pelvic Organ Prolapse, Urinary Incontinence, and Infections. Pages 309-324.
Pelvic Relaxation and Urinary Incontinence
Preceptor Handout
Patients with conditions of pelvic relaxation and urinary incontinence present in a variety
of ways. The physician should be familiar with the types of pelvic relaxation and
incontinence, and the approach to management of these patients.
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
A 75-year-old woman G5P5 presents for an annual exam and reports having a “fullness”
in the vaginal area. The symptom is more noticeable when she is standing for a long
period of time. She does not complain of urinary or fecal incontinence. She has no other
urinary or gastrointestinal symptoms. There has been no vaginal bleeding. Her past
medical history is significant for well-controlled hypertension and chronic bronchitis.
She has never had surgery.
Pelvic exam reveals normal appearing external genitalia except for generalized atrophic
changes. The vagina and cervix are without lesions. A cystocele and rectocele are noted.
The cervix descends to the introitus with the patient in an upright position. Uterus is
normal size. Right and left ovaries are not palpable. No rectal masses are noted. Rectal
sphincter tone is slightly decreased. The patient prefers non-surgical treatment. A
pessary is placed and you prescribe vaginal estrogen to address atrophic changes.
Discussion Questions:
Pessaries may cause vaginal irritation and ulceration. They are better
tolerated when the vaginal epithelium is well estrogenized
Exogenous estrogen may be required in the hypoestrogenic patient
Oral estrogen is not recommended to prevent or treat urinary
incontinence
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 29 Pelvic Relaxation, Urinary
Incontinence, and Urinary Tract Infection. Pages 288-298.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 24
Genitourinary Dysfunction: Pelvic Organ Prolapse, Urinary Incontinence, and Infections. Pages 309-324.
TEACHING CASE 37
Endometriosis
Student Handout
Clinical Case:
On physical exam you notice a 4mm hyperpigmented, raised, non-tender nodule in the
umbilical area. The pelvic exam showed a fixed, retroverted uterus. The uterosacral
ligaments on both sides are nodular and mildly tender. A 5 cm right adnexal mass was
palpated and tender. The left ovary was slightly enlarged. Ultrasound of the abdomen
showed an echogenic cystic mass in the right ovary, which measured 4 cm in diameter.
The left ovary was reported as normal.
Discussion Questions:
2. What are some of the physical exam findings associated with endometriosis?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 30 Endometriosis. Pages 299-307.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 26
Endometriosis and Adenomyosis. Pages 334-340.
Endometriosis
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
On physical exam you notice a 4mm hyperpigmented, raised, non-tender nodule in the
umbilical area. The pelvic exam showed a fixed, retroverted uterus. The uterosacral
ligaments on both sides are nodular and mildly tender. A 5 cm right adnexal mass was
palpated and tender. The left ovary was slightly enlarged. Ultrasound of the abdomen
showed an echogenic cystic mass in the right ovary, which measured 4 cm in diameter.
The left ovary was reported as normal.
Discussion Questions:
2. What are some of the physical exam findings associated with endometriosis?
History and physical exam are first steps due to variety of presentations
Direct visualization is needed for establishing a diagnosis
Tissue biopsy makes definitive diagnosis
Pelvic sonogram cannot make diagnosis, but can exclude other conditions
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 30 Endometriosis. Pages 299-307.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 26
Endometriosis and Adenomyosis. Pages 334-340.
CLINICAL CASE 38
A 24-year old woman presents to you as a self-referral for pelvic pain. She describes a
four-year history of intermittent lower abdominal and pelvic pain that is now constant
in nature. The pain is always present, sometimes sharper in the left lower quadrant
and not related to menses. She has occasional nausea and is sometimes constipated.
Nothing makes the pain better or worse. Over the years, she has used acetaminophen
and ibuprofen, and has not found any relief. She began her menses at age 13 and they
have come on a regular monthly basis. She experiences some premenstrual bloating
and has cramps with her periods, and reports discomfort at other times of the month.
She had a trial of oral contraceptives and then a subsequent laparoscopy by a prior
gynecologist. She was told that everything looked normal. She is otherwise a healthy
non-smoker, but reports that this pain is making her life miserable.
She has a bachelor’s degree from a local college, works as computer processor and lives
at home with her parents. She has never been sexually active. Upon further questioning,
she reports that her oldest brother sexually abused her as a child.
Physical exam
Somewhat flattened affect, but smiles occasionally. 5 feet 4 inches; 142 pounds.
Trapezius and paraspinous muscles tender on palpation. No costovertebral angle
tenderness. Abdomen is soft with 2 well-healed pelviscopy incisions. There is no
rebound or guarding or mass. Tenderness is elicited with deep palpation of the lower
quadrants. External genitalia, vagina and cervix are normal. Uterus is mid-position,
mobile and the adnexa are mildly tender. The rectal vault is palpably normal with soft
stool that is heme negative.
Gynecologic origin
Gastrointestinal disorders
Urinary problems
Musculoskeletal disease
Pain processing disorders
Psychiatric and psychological
Management plan
The patient was counseled about the multiple possible causes of chronic pelvic pain.
The provider was empathic and sensitive in regards to this challenging problem. A plan
of care was devised jointly and she was scheduled for a follow-up. The patient’s
previous records and operative report was obtained and reviewed. On a subsequent
visit, the patient did note that the pain worsens when her older brother returns home
for family holidays. She reports that she has never mentioned this to the therapist that
she has recently started seeing. A trial of low dose tricyclic antidepressants was
initiated which helped the patient with sleeping, but did not make the pain go away.
The patient continued to follow up at regularly scheduled intervals with her
gynecologist and therapist, and had less emergency room visits.
Teaching points
Chronic pelvic pain can be defined as cyclic pain of 6 months duration or non-cyclic pain
of 3 months duration and the pain interferes with normal activities. The problem of
chronic pelvic pain is under-recognized. It may affect 15% to 24% of American women
and accounts for a large proportion of office visit time and many invasive surgical
procedures.
Chronic pelvic pain can be derived from a variety of sources, including gynecologic,
gastrointestinal, rheumatologic, musculoskeletal, urologic or psychiatric. It can be
difficult to diagnose the etiology and can be challenging to treat. The health care
provider must perform a thorough history and physical exam, which are often much
more valuable in making a diagnosis than any laboratory or radiologic tests.
Patients present to different specialists based on their belief of what is causing the pain.
Gastrointestinal diseases may cause symptoms such as nausea, vomiting, bloating or
changes in bowel habits. Urinary tract disorders my cause dysuria, urgency or vague
pelvic discomfort. Patients need to be asked about fatigue, sleep disturbances, or mood
disorders and fibromyalgia and depression considered. Patients also need to be queried
about physical and sexual abuse, or any history of substance abuse. Musculoskeletal
disorders can be determined by a thorough motor and sensory examination, with
attention to the back, hips and legs.
Even when the etiology is determined, chronic pelvic pain can be difficult to treat. The
patient may need to be seen regularly and provided with much support. Co-
management with a psychologist, social worker or therapist may be helpful.
UNIT THREE:
SECTION B
GYNECOLOGY - Breasts
Clinical Case:
A 56-year-old woman G0P0 made an appointment to see her gynecologist because she
was concerned about a small lump in her right breast that she has been able to feel for 2
months. She has not had breast problems in the past and does not have a family history
of breast cancer. There are no apparent skin changes, asymmetry or skin dimpling.
Axillary or subclavian lymph nodes are not palpable. Breasts are symmetric, diffusely
cystic and non-tender. There is an area of firmness approximately 1 cm in diameter
with indiscreet boarders at 9:00 on her right breast. The area is slightly different in
consistency than the rest of the surrounding tissue. The patient was sent for a
mammogram that revealed dense breast tissue, but no discrete mammographic
abnormalities.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 32 Disorders of the Breast. Pages
316-327.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 30 Breast
Disease: A Gynecologic Perspective. Pages 364-371.
Disorders of the Breast
Preceptor Handout
Every physician should understand the basic approach to evaluating the common
symptoms associated with the breast.
The APGO Educational Objectives related to this topic are the following:
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Disorders of the Breast
Preceptor Handout
Clinical Case:
A 56-year-old woman G0P0 made an appointment to see her gynecologist because she
was concerned about a small lump in her right breast that she has been able to feel for 2
months. She has not had breast problems in the past and does not have a family history
of breast cancer. There are no apparent skin changes, asymmetry or skin dimpling.
Axillary or subclavian lymph nodes are not palpable. Breasts are symmetric, diffusely
cystic and non-tender. There is an area of firmness approximately 1 cm in diameter
with indiscreet boarders at 9:00 on her right breast. The area is slightly different in
consistency than the rest of the surrounding tissue. The patient was sent for a
mammogram that revealed dense breast tissue, but no discrete mammographic
abnormalities.
Discussion Questions:
Annual exam
Inspection (with patient sitting) - check for contour, symmetry, skin
changes or nipple retraction
Palpation (in upright and supine positions) of breast, areola and nipples;
examine axillae; examine supraclavicular fossae
Intraductal Papilloma
1. Commonly found in peri and menopausal patients
2. Bloody, serous or turbid nipple discharge
3. Excisional biopsy is often needed
Galactocele
1. Cystic dilatation of a duct filled with thick, milky fluid
2. Secondary infection causes mastitis
3. Needle aspiration, often curative
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 32 Disorders of the Breast. Pages
316-327.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 30 Breast
Disease: A Gynecologic Perspective. Pages 364-371.
UNIT THREE:
SECTION C
GYNECOLOGY - Procedures
Gynecologic Procedures
Student Handout
Clinical Case:
The patient is a 40 year old G0 who has menorrhagia due to a fibroid uterus. She has
anemia with a hematocrit of 27% despite oral iron therapy. She has periods lasting 10-
12 days each month. She also suffers from lupus and anti-phosphlipid antibody
syndrome, diagnosed when she was 25. Her manifestations mostly are arthritis, but she
has a history of a deep venous thrombosis (DVT) 6 years ago. Although her lupus
currently is not flaring, she takes prednisone 5 mg per day as well as coumadin 2.5 mg
per day. She does not have other medical problems and her only other surgery was a
tonsillectomy at age 16, during which she was told she had “more than usual bleeding”
but did not require transfusion. She desires definitive surgical management with
hysterectomy. She is married, works as an office manager, and never had children
because of her lupus. Her physical exam shows BP 120/70, weight of 160, height of
5’6”. She has a number of small bruises on her extremities. Her uterus is palpable just
under her umbilicus, but is non-tender. Pelvic exam is only significant for the enlarged
uterus. Pelvic ultrasound confirms a large fibroid uterus, normal ovaries. Labs show
INR of 2.5, normal chem. panel.
Discussion Questions:
4. Which other health professionals would you consult both pre- and post-operatively?
5. What measures can you take post-operatively to assess for and diagnose
complications?
6. On post-operative day 2, the patient complains of feeling short of breath and her
pulse oximeter shows an oxygen saturation of 89% on room air. How would you
proceed?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 33 Gynecologic Procedures. Pages
328-337.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 31
Gynecologic Procedures. Pages 372-384.
Gynecologic Procedures
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
E. Descsribe each procedure and list the indications and complications of each of the
following:
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Gynecologic Procedures
Preceptor Handout
Clinical Case:
The patient is a 40 year old G0 who has menorrhagia due to a fibroid uterus. She has
anemia with a hematocrit of 27% despite oral iron therapy. She has periods lasting 10-
12 days each month. She also suffers from lupus and anti-phosphlipid antibody
syndrome, diagnosed when she was 25. Her manifestations mostly are arthritis, but she
has a history of a deep venous thrombosis (DVT) 6 years ago. Although her lupus
currently is not flaring, she takes prednisone 5 mg per day as well as coumadin 2.5 mg
per day. She does not have other medical problems and her only other surgery was a
tonsillectomy at age 16, during which she was told she had “more than usual bleeding”
but did not require transfusion. She desires definitive surgical management with
hysterectomy. She is married, works as an office manager, and never had children
because of her lupus. Her physical exam shows BP 120/70, weight of 160, height of
5’6”. She has a number of small bruises on her extremities. Her uterus is palpable just
under her umbilicus, but is non-tender. Pelvic exam is only significant for the enlarged
uterus. Pelvic ultrasound confirms a large fibroid uterus, normal ovaries. Labs show
INR of 2.5, normal chem. panel.
Discussion Questions:
4. Which other health professionals would you consult both pre- and post-operatively?
Hematology for management of anti-coagulation
Rheumatology for management of lupus and possible steroid boost
Anesthesiology to alert them to her high risk status
5. What measures can you take post-operatively to assess for and diagnose
complications?
Serial hematocrits
Judicious re-start of her anti-coagulation after the immediate peri-operative
period
Urine output assessment
Continuous pulse oximetry
Physical exam
6. On post-operative day 2, the patient complains of feeling short of breath and her pulse
oximeter shows an oxygen saturation of 89% on room air. How would you proceed?
Spiral CT
Oxygen
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 33 Gynecologic Procedures. Pages
328-337.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 31
Gynecologic Procedures. Pages 372-384.
UNIT FOUR:
REPRODUCTIVE ENDOCRINOLOGY,
INFERTILITY AND RELATED TOPICS
41. Puberty
42. Amenorrhea
43. Hirsutism and Virilization
44. Normal and Abnormal Uterine Bleeding
45. Dysmenorrhea
46. Climacteric / Menopause
47. Infertility
48. Premenstrual Syndrome & Premenstrual Dysphoric Disorder
CLINICAL CASE 41
Puberty
A 15-year-old female comes in for exam because she has not had her period. She
seemed to be developing normally and had normal breast development that started
about 2 years ago; she has pubic hair. She met her developmental milestones and is of
normal height and weight. She has not had any significant medical illnesses. Her ROS is
negative and her family history is negative.
She is active in school and is a cheerleader. She works out with the team and runs. She
does well in school. She lives at home with her mom, dad and sister. She does not
currently have a boyfriend and has not been sexually active.
Physical exam:
HEENT-WNL:
At this point, because her physical finding are considered to be WNL and it does not
seem as if there is an anatomic reason for her amenorrhea and slight delay in pubic hair
development that this likely just delayed puberty and reassurance can be given.
However patient is sent home with prescription for Provera to determine if her
endometrium is estrogen primed and therefore with intact pituitary and ovarian
function.
Discussion/teaching points:
Tanner staging evaluates the stages of breast and pubic hear development
Tanner stage 1- pre-pubertal breast; Tanner stage 2-breast bud; Tanner stage 3-further
breast and areolar enlargement; Tanner stage 4-aerola and papilla form secondary
mound; Tanner stage 5-mature stage pubic hair development; Tanner stage 1-no pubic
hair; Tanner stage 2-sparse hair on labia majora; Tanner stage 3, -pubic hair to mons
pubis; Tanner stage 4 adult hair with no spread to thighs; Tanner stage 5- spread to
thighs.
The patient has normal anatomical findings, so this rules out androgen insensitivity as
well as mullerian agenesis. Additionally, one can treat with Provera to check for an
estrogen-primed endometrium. This will help determine if the pituitary and ovarian
hormones are adequate to produce estrogen and the hypothalamic/pituitary/ovarian
axis has not matured to the point of producing an ovulatory cycle and withdrawal bleed.
If the patient has a withdrawal bleed, reassurances can be given to her and her mother
that these are normal findings and she is just a little slower to mature. One could also
consider treating intermittently with Provera to ensure a regular withdrawal bleed and
to not interfere with the maturation process of the hypothalamic/pituitary/ovarian
axis.
TEACHING CASE 42
Amenorrhea
Student Handout
Clinical Case:
A 26-year-old G2P2 woman presents because of no periods for 9 months. She delivered
two full term healthy children vaginally and their ages are 5 and 3. She breastfed her
youngest for 1 year, menses returned right after she stopped, and were monthly and
normal until 9 months ago. She is not using any contraception, although intercourse is
infrequent. She feels very fatigued, has frequent headaches and has had trouble losing
weight. She has no history of abnormal Paps or STI’s. She takes no medications. She is
married and works from home as a computer consultant. On exam, BP= 120/80, P= 64,
Ht= 5’8”, Wt= 160 pounds. She appears tired but in no distress. Breasts show scant
bilateral milky white discharge with manual stimulation. Breast exam reveals no
masses, dimpling or retraction. Exam is otherwise normal, including pelvic exam. HCG
is negative.
Discussion Questions:
4. Consider that this patient has a prolactin level of 130. The test, when repeated with
the patient fasting is 100. What is your next step?
5. How would your next step differ if the patient had normal labs with an estradiol level
of 30pcg/ml and an FSH of 2mIU. What treatment would you offer her? What is she
at risk for?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 36 Amenorrhea and Dysfunctional
Uterine Bleeding. Pages 359-364.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 33
Amenorrhea, Oligomenorrhea, and Hyperandrogenic Disorders. Pages 398-408.
Amenorrhea
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
A 26-year-old G2P2 woman presents because of no periods for 9 months. She delivered
two full term healthy children vaginally and their ages are 5 and 3. She breastfed her
youngest for 1 yr, menses returned right after she stopped, and were monthly and
normal until 9 months ago. She is not using any contraception, although intercourse is
infrequent. She feels very fatigued, has frequent headaches and has had trouble losing
weight. She has no history of abnormal Paps or STI’s. She takes no medications. She is
married and works from home as a computer consultant. On exam, BP= 120/80, P= 64,
Ht= 5’8”, Wt= 160 pounds. She appears tired but in no distress. Breasts show scant
bilateral milky white discharge with manual stimulation. Breast exam reveals no
masses, dimpling or retraction. Exam is otherwise normal, including pelvic exam. HCG
is negative.
Discussion Questions:
4. Consider that this patient has a prolactin level of 130. The test, when repeated with the
patient fasting is 100. What is your next step?
Pituitary MRI
Treat with dopamine agonist like bromocriptine
Normal menses and fertility very likely to return, needs contraception
5. How would your next step differ if the patient had normal labs with an estradiol level of
30pcg/ml and an FSH of 2mIU/ml. What treatment would you offer her? What is she at
risk for?
Hypothalamic amenorrhea, most likely due to stress
Replace estrogen in order to protect against osteoporosis
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 36 Amenorrhea and Dysfunctional
Uterine Bleeding. Pages 359-364.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 33
Amenorrhea, Oligomenorrhea, and Hyperandrogenic Disorders. Pages 398-408.
CLINICAL CASE 43
None
Ob-Gyn history:
G0. LMP: 2 months ago. Menarche: 13 years old. Cycle length: every 2-4 months.
Duration: 7-10 days with heavy flow for the first 3 days. No STD history. She has been
sexually active and has used condoms for contraception. No prior pap smear.
None
Social history:
She smokes ½ pack of cigarettes per day for 8 years. Occasional alcohol. No street
drugs. She works as a bus driver.
Family history:
A number of family members are obese. Mother has irregular cycles, obesity, diabetes,
hypertension and similar facial hair growth. Her father had some balding, obesity,
hypertension and died of a heart attack at age 50. Her sister is obese, has irregular
cycles, similar facial hair growth and she has 2 children. Her 2 brothers are healthy,
except for being overweight.
HEENT: NC/AT
Terminal hair is noted on the upper outer 1/3 of lip, few sparse hairs in the sideburn
area and chin, neck with hair recently shaved.
Abdomen: NT, ND, obese, No hepatosplenomegaly and No striae. Terminal hair noted in
a vertical band below the umbilicus.
Extremities: Non-tender. No edema. DTRs: 2+/= bilaterally. Upper inner thighs with
sparse terminal hair.
Pelvic exam:
Laboratory or studies:
Hirsutism
Chronic anovulation
Obesity
Hyperplasia without atypia
Management:
This patient was treated with oral contraceptive pills. She will return at the end of 6
months for re-evaluation and possible treatment with an anti-androgen such as
spironolactone to further control her hirsutism. She was also counseled regarding
weight loss and exercise. She was referred to a nutritionist.
Regarding fertility, she was reassured that with appropriate weight loss and after
stopping the birth control pill, she may begin ovulating on her own. However, if she
does not start to cycle, she would be an excellent candidate for a fertility medication,
such as clomiphene citrate. She would have about a 60% chance of ovulating on that
medication without the need for stronger medication. Metformin or other insulin-
sensitizing agent may also enhance her response to clomiphene citrate without
increasing her chance for multiple gestations.
Teaching points:
1. This patient has the diagnosis of polycystic ovary syndrome (PCOS). This
diagnosis is made on the clinical triad of hirsutism and chronic anovulation
after ruling out other abnormalities. Other diagnoses that may present
similarly to PCOS include: hypothyroidism, late-onset congenital adrenal
hyperplasia and Cushing’s syndrome. The normal 17-hydroxyprogesterone
level ruled out congenital adrenal hyperplasia and the physical examination
ruled out Cushing’s syndrome. If there were any concern about the
possibility of Cushing’s syndrome, a dexamethasone suppression test or a 24-
hour urine free cortisol test would be appropriate. It is not necessary to
measure FSH and LH to look for a 1:3 ratio. With the newer immunocyte
assay systems, this ratio is more likely to be 1:1 or slightly increased in the
LH direction; it is much less likely to be present as a 1:3 ratio.
2. Patients with PCOS who have been left untreated for prolonged periods of
time are at increased risk for endometrial cancer due to unopposed estrogen.
Case reports exist where PCOS patients are diagnosed with endometrial
cancer in the mid-twenties. It is important to evaluate these patients prior to
initiating hormonal therapy. An endometrial biopsy is warranted in these
patients despite being under 35-years-old.
3. PCOS patients are also at increased risk for diabetes and deserve screening
with a fasting glucose level.
4. When this patient desires to conceive, she should discontinue the oral
contraceptive and anti-androgen (if she is taking one). She may continue to
have regular menstrual cycles, particularly if she has lost weight and is now
within 10% of her ideal body weight. After a few months, if she is again
anovulatory, she will likely need a progestin to start her cycle and then she
should be treated with a fertility drug, such as clomiphene citrate, with or
without an insulin-sensitizing agent. Approximately 60% of anovulatory
women respond to clomiphene alone and some respond to combination
therapy. If there is no response, she may need a referral to a reproductive
endocrinologist for gonadotropin therapy and/or IVF.
6. Increasing the sex hormone binding globulin (so there is less free
testosterone), reducing androgen production, blocking androgen receptors,
or interfering with the 5-alpha reductase enzyme will improve hirsutism.
Medical treatment with birth control pills or antiandrogens are effective at
slowing down hair growth. However, these treatments will not remove
terminal hair that is already present. Physical measures are recommended
after the endocrine abnormality is corrected. These treatments include
depilatories, bleaching agents, shaving/plucking, waxing, electrolysis and
laser. The only two permanent procedures are electrolysis and laser therapy,
where the hair follicle is actually treated.
A 45-year-old G2P0020, LMP 21 days ago, presents with heavy menstrual bleeding.
Prior to 6 months ago her cycles came every 28-30 days, lasted for 6 days, and were
associated with cramps that were relieved by ibuprofen. In the last 6 months there has
been a change with menses coming every 25-32 days, lasting 7-10 days and associated
with cramps not relieved by ibuprofen, passing clots and using 2 boxes of maxi pads
each cycle. She is worried about losing her job if the bleeding is not better controlled.
She denies dizziness, but complains of feeling weak and fatigued. Her weight has not
changed in the last year. She denies any bleeding disorders or reproductive cancers in
the family. She uses condoms for contraception. She takes no daily medications and has
no other medical problems. She is married and works in a factory. On exam,
BP=130/88; P= 100; Ht=5’6’; Wt=150 pounds. She appears pale. Pelvic exam shows
normal vulva, vagina and cervix: normal size, mildly tender, mobile uterus; non-tender
adnexae without palpable masses. Labs show Hgb: 9.0, HCT: 27%, HCG: negative,
Endometrial biopsy: normal secretory endometrium, Pelvic ultrasound: heterogeneous
myometrium, endometrial lining 1.4cm and irregular consistent with endometrial
polyp, normal ovaries.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 36 Amenorrhea and Dysfunctional
Uterine Bleeding. Pages 359-364.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 34
Dysfunctional Uterine Bleeding. Pages 409-412.
Normal and Abnormal Uterine Bleeding
Preceptor Handout
The occurrence of bleeding at times other than expected menses is a common event.
Accurate diagnosis of abnormal uterine bleeding is necessary for appropriate
management.
The APGO Educational Objectives related to this topic are the following:
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Normal and Abnormal Uterine Bleeding
Preceptor Handout
A 45-year-old G2P0020, LMP 21 days ago, presents with heavy menstrual bleeding.
Prior to 6 months ago her cycles came every 28-30 days, lasted for 6 days, and were
associated with cramps that were relieved by ibuprofen. In the last 6 months there has
been a change with menses coming every 25-32 days, lasting 7-10 days and associated
with cramps not relieved by ibuprofen, passing clots and using 2 boxes of maxi pads
each cycle. She is worried about losing her job if the bleeding is not better controlled.
She denies dizziness, but complains of feeling weak and fatigued. Her weight has not
changed in the last year. She denies any bleeding disorders or reproductive cancers in
the family. She uses condoms for contraception. She takes no daily medications and has
no other medical problems. She is married and works in a factory. On exam,
BP=130/88; P= 100; Ht=5’6’; Wt=150 pounds. She appears pale. Pelvic exam shows
normal vulva, vagina and cervix: normal size, mildly tender, mobile uterus; non-tender
adnexae without palpable masses. Labs show Hgb: 9.0, HCT: 27%, HCG: negative,
Endometrial biopsy: normal secretory endometrium, Pelvic Ultrasound: heterogeneous
myometrium, endometrial lining 1.4cm and irregular consistent with endometrial
polyp, normal ovaries.
Discussion Questions:
Discuss how these etiologies can be divided into ovulatory (anatomic) disorders and
anovulatory disorders
Note that hyperplasia and cancer, although “anatomic,” are primarily associated with
anovulation, or unopposed estrogen.
3. Discuss the mechanism for anovulatory bleeding
Progesterone withdrawal signals the endometrium to shed in a uniform way by
causing spiral artery spasm. Women who don’t ovulate don’t have progesterone
withdrawal, and usually have bleeding due to unopposed estrogen with either
estrogen withdrawal or estrogen excess. Neither of these mechanisms causes
spiral artery spasm, and therefore can result in non-uniform shedding of the
lining at irregular intervals.
Discuss endometrial phases (proliferative and secretory), normal endocrinologic
events of the menstrual cycle, and the role of laboratory tests for progesterone in
diagnosing ovulation.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 36 Amenorrhea and Dysfunctional
Uterine Bleeding. Pages 359-364.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 34
Dysfunctional Uterine Bleeding. Pages 409-412.
CLINICAL CASE 45
Dysmenorrhea
You speak to the patient without her mother and ask if she has ever been sexually active
in any way. The patient denies this activity and you believe her. She is a good student, is
involved in sports and after school programs, and you think it is unlikely that she is
pretending to have dysmenorrhea to get out of school. She denies use of drugs or
alcohol, and you believe it is unlikely she is drug seeking. She says that she gets partial
relief by using 3-4 Advil, two or three times a day during her period.
The review of systems, past medical history and social history are noncontributory. The
patient’s mother, but no other relatives, has endometriosis.
Physical exam:
The patient’s vital signs are normal and she is afebrile. Abdominal exam reveals no
masses or organomegaly, and no tenderness or rebound. Because the patient is virginal
and you do not want to induce undue pain, you defer the pelvic exam and do a rectal
exam showing a normal size non-tender uterus, which is mobile and anteflexed. There
are no nodules on the back of the uterus, and there are no adnexal masses or
tenderness.
Laboratory:
Diagnosis:
High likelihood of primary dysmenorrhea based on the onset of pain and associated
systemic symptoms with regular cycles, and partial response to Advil.
Secondary dysmenorrhea due to endometriosis is possible, but less likely based on the
normal uterus and ovaries at the time of physical exam, and the short time this patient
has been menstruating. However, this is a familial condition and her mother has
endometriosis.
Management:
If this is not sufficient or if she develops gastric upset with this treatment, combined
oral contraception are very likely to help this condition (whether it is primary
dysmenorrhea or secondary dysmenorrhea due to endometriosis. However, her mother
may be concerned about the use of oral contraceptives, worrying that it might increase
the likelihood of sexual activity. You can tell her there is data showing that medical use
of oral contraceptives is not associated with increased sexual activity.
If these two treatments are not successful, you plan on referring her to a gynecologist
for further workup.
Teaching points:
Primary dysmenorrhea: Onset is usually in the teens to twenties with the onset of
ovulation. Some studies indicate it is present in up to 90% of teenagers. Because it is
believed to be due to an excess of prostaglandin F2AlPHA (PGF2a)production in the
endometrium. This potent smooth-muscle stimulant causes intense uterine
contractions and resulting pain. It also gets into the systemic circulation resulting in (by
decreasing frequency) nausea, tiredness, nervousness, dizziness, diarrhea and
headache in up to 45% of patients. There are no abnormal physical findings in the
gynecological exam for primary dysmenorrhea. The diagnosis is one of exclusion.
Extrauterine causes
Endometriosis (endometrial glands outside the uterus)
Tumors (benign or malignant) or cysts
Inflammation
Adhesions
Psychogenic (rare)
Non-gynecologic causes
Intramural causes
Adenomyosis (endometrial glands in the wall of the uterus)
Leiomyomata (fibroids/benign tumors in the wall of the uterus)
Intrauterine causes
Leiomyomata
Polyps
Intrauterine contraceptive devices (IUDs)
Infection
Cervical stenosis and cervical lesions
Menopause
Student Handout
Clinical Case:
A 53-year-old, G3P3, whose last menstrual period was 4 months ago presents to the
office with hot flashes, emotional lability, and insomnia. She experiences the hot flashes
2-3 times per day and occasionally at night. She has been having trouble sleeping and is
extremely fatigued. Since age 14, her periods have been regular until 2 years ago, when
they began to space out to every 2-3 months. She is sexually active and recently has
noted some dyspareunia. The patient works as a receptionist and rarely exercises. She
smokes 2 packs of cigarettes a day and drinks alcohol socially. She recently started
taking a soy supplement. She does not have any pertinent gynecological, medical or
surgical history. Her family history is significant for her mother sustaining a hip
fracture at age 60 and a sister with breast cancer and high cholesterol. On examination,
she has normal vital signs and she is 123 lbs and 5’4” tall. On pelvic examination, she
has mildly decreased vaginal rugae and a pale, small cervix. No masses or tenderness
are palpated on bimanual exam.
Discussion Questions:
6. What laboratory and diagnostic tests would you order for this patient?
References:
Essentials of Obstetrics and Gynecology by Hacker and Moore, 4th Edition, Chapter 34.
Obstetrics and Gynecology by Beckmann, et al, 5th Edition, Chapter 38.
Menopause
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
A 53-year-old, G3P3, whose last menstrual period was 4 months ago presents to the
office with hot flashes, emotional lability, and insomnia. She experiences the hot flashes
2-3 times per day and occasionally at night. She has been having trouble sleeping and is
extremely fatigued. Since age 14, her periods have been regular until 2 years ago, when
they began to space out to every 2-3 months. She is sexually active and recently has
noted some dyspareunia. The patient works as a receptionist and rarely exercises. She
smokes 2 packs of cigarettes a day and drinks alcohol socially. She recently started
taking a soy supplement. She does not have any pertinent gynecological, medical or
surgical history. Her family history is significant for her mother sustaining a hip
fracture at age 60 and a sister with breast cancer and high cholesterol. On examination,
she has normal vital signs and she is 113 lbs and 5’4” tall. On pelvic examination, she
has mildly decreased vaginal rugae and a pale, small cervix. No masses or tenderness
are palpated on bimanual exam.
Discussion Questions:
This patient’s risk factors include menopause, reduced weight for height, family
history of osteoporosis, cigarette smoking, and sedentary lifestyle.
Additional risk factors for discussion include age at menopause or
oophorectomy, white or Asian origin, calcium intake, parity, alcohol and caffeine
intake, and corticosteroid use.
4. How do you diagnose and treat atrophic vaginitis?
Patient usually has vulvar irritation and a moderate discharge (clear or yellow,
can be blood-tinged). Associated urinary symptoms may be present.
Examination shows a clear, watery discharge, with vulvar erythema. Excoriation
may be present. A pale vaginal mucosa, with patches of erythema and even
superficial blood vessels are consistent with atrophy.
The pale or yellow discharge has a pH of 5.5 or higher.
Basal cells replace superficial vaginal epithelial cells and can be seen on a saline
wet mount or Pap test.
Treatment is estrogen and takes 4 to 6 weeks for symptomatic relief.
Associated infections should be treated-consider a sulfa cream.
Discuss importance of evaluating any postmenopausal bleeding.
Risks and benefits of therapy should be reviewed (WHI and other studies).
Contraindications should be discussed.
Treatment options for menopausal symptoms and osteoporosis should be
outlined.
Acknowledge frequent use of complementary and alternative treatments.
Lifestyle modifications should be stressed.
6. What laboratory and diagnostic tests would you order for this patient?
Laboratory and diagnostic tests should focus on the patient’s history and
symptoms, as well as preventive screening. For example, a TSH should be sent
due to her fatigue and a lipid profile due to the family history. A bone density is
indicated as well.
General health maintenance/screening tests should be ordered. These include a
mammogram, bone density, colonoscopy, etc.
Discuss the guidelines for ordering the above tests (i.e. colonoscopy at age 50,
bone density at age 65, etc.)
Consider discussing new Pap test recommendations.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 38 Menopause. Pages 374-383.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 36
Climacteric. Pages 422-428.
TEACHING CASE 47
Infertility
Student Handout
Clinical Case:
A 37-year-old female and her 37-year-old husband present with the complaint of a
possible fertility problem. The couple has been married for 2 years. The patient has a 4-
year-old daughter from a previous relationship. The patient used birth control pills
until one-and-a- half-years-ago. The couple has been trying to conceive since then and
report a high degree of stress related to their lack of success. The patient reports good
health and no problems in conceiving her previous pregnancy or in the vaginal delivery
of her daughter. She reports that her periods were regular on the birth control pill, but
have been irregular since she discontinued taking them. She reports having periods
every 5-7 weeks. Past history is remarkable only for mild depression. Imipramine 150
mg qhs for the last 8 months is her only medication. She works as a cashier, runs 12-24
miles each week for the last 2 years, and has no history of STDs, abnormal Paps,
smoking, alcohol or other drugs. She has had no surgery.
The patient’s partner also reports good health and reports no problems with erection,
ejaculation or pain with intercourse. He has had no prior urogenital infections or
exposure to STDs. He has had unprotected sex prior to his current relationship, but has
not knowingly conceived. He has no medical problems or past surgery. He works as a
long-distance truck driver and is on the road 2-3 weeks each month. He smokes a pack
of cigarettes a day since age 18 and drinks 2-3 cans of beer 3-4 times a week when he’s
not driving. He occasionally uses amphetamines to stay awake while driving at night.
The couple has vaginal intercourse 3-5 times per week when he is at home.
The patient is 5’9” and weighs 130 pounds. Breast exam reveals no tenderness or
masses, but bilateral galactorrhea on compression of the areola. Pelvic exam reveals
normal genitalia, a well-estrogenized vaginal vault mucosa and cervical mucus
consistent with the proliferative phase. The uterus is anteflexed and normal in size
without masses or tenderness. Several tests were ordered.
Discussion Questions:
3. What is the initial work-up for infertile couples and what tests would you add for
this particular couple?
4. Studies were reviewed and showed a normal TSH, a prolactin of 60 ng/ml (normal
range < 20 ng/ml) and a semen analysis with 2cc of semen, 4 million sperm per ml,
30% normal forms and 20% motility. Basal body temperature chart shows a
monophasic temperature graph. What is the differential diagnosis at this point?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 39 Infertility. Pages 384-395.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 35 Infertility
and Assisted Reproductive Technologies. Pages 413-421.
Infertility
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
A. Define infertility *
B. Describe the causes of male and female infertility *
C. Describe the evaluation and management of infertility
D. List the psychosocial issues associated with infertility
Clinical Case:
A 37-year-old female and her 37-year-old husband present with the complaint of a
possible fertility problem. The couple has been married for 2 years. The patient has a 4-
year-old daughter from a previous relationship. The patient used birth control pills
until one-and-a- half-years-ago. The couple has been trying to conceive since then and
report a high degree of stress related to their lack of success. The patient reports good
health and no problems in conceiving her previous pregnancy or in the vaginal delivery
of her daughter. She reports that her periods were regular on the birth control pill, but
have been irregular since she discontinued taking them. She reports having periods
every 5-7 weeks. Past history is remarkable only for mild depression. Imipramine 150
mg qhs for the last 8 months is her only medication. She works as a cashier, runs 12-24
miles each week for the last 2 years, and has no history of STDs, abnormal Paps,
smoking, alcohol or other drugs. She has had no surgery.
The patient’s partner also reports good health and reports no problems with erection,
ejaculation or pain with intercourse. He has had no prior urogenital infections or
exposure to STDs. He has had unprotected sex prior to his current relationship, but has
not knowingly conceived. He has no medical problems or past surgery. He works as a
long-distance truck driver and is on the road 2-3 weeks each month. He smokes a pack
of cigarettes a day since age 18 and drinks 2-3 cans of beer 3-4 times a week when he’s
not driving. He occasionally uses amphetamines to stay awake while driving at night.
The couple has vaginal intercourse 3-5 times per week when he is at home.
The patient is 5’9” and weighs 130 pounds. Breast exam reveals no tenderness or
masses, but bilateral galactorrhea on compression of the areola. Pelvic exam reveals
normal genitalia, a well-estrogenized vaginal vault mucosa and cervical mucus
consistent with the proliferative phase. The uterus is anteflexed and normal in size
without masses or tenderness. Several tests were orderd.
Discussion Questions:
3. What is the initial work-up for infertile couples and what tests would you add for
this particular couple?
Physical examination
Medical history
Semen analysis
Check for ovulation – basal body temperature, ovulation prediction kits,
luteal phase serum progesterone
Hysterosalpingogram: check for normal uterus and open fallopian tubes
Discussion about frequency and timing of intercourse
For this couple specifically, TSH and prolactin
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 39 Infertility. Pages 384-395.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 35 Infertility
and Assisted Reproductive Technologies. Pages 413-421.
CLINICAL CASE 48
GS, a 37-year-old married woman, comes to your office for an “annual checkup.” She has
recently moved to town, and all her previous medical care was in a different city. She
has not seen a gynecologist for 2 years and states that she wants to establish a
relationship with a physician in her new surroundings.
The patient is a gravida 3, para 3. She has regular periods, although they have gotten
somewhat longer in the past year or so. She is currently not sexually active and is taking
no medications or supplements.
Past history reveals that she underwent an appendectomy as a child and has had two
diagnostic laparoscopies for pelvic pain, with the most recent done 3 years ago. She
has no pain at the present time, has no medical conditions and is not allergic to any
medications.
Her family history reveals that her mother suffered from depression. Her 40-year-old
sister was recently diagnosed with breast cancer. Upon review of systems, she
describes occasional constipation and diarrhea. She has recently had difficulty sleeping
and feels that she gets tired more easily than she should. Upon further questioning, she
reveals that she has difficulty falling asleep, often because she is thinking about what
has happened during the day and/or what may be coming up the next day. The patient
and her three children have recently moved to town, while her husband has remained
in their previous city to fulfill his job obligation. This domestic separation has been
going on for approximately 6 months.
On physical examination, all findings are normal. The patient did appear to be a bit
nervous and startled easily as you entered the room.
On further questioning, the patient thinks that her jitteriness and sleeplessness have led
to increased irritability with the children. She worries a great deal, particularly about
her domestic situation and being separated from her husband. She has difficulty
concentrating at her job (she works as a bank teller) and also feels that her memory is
failing her, as she loses her keys or misplaces items at home from time to time. Further
questioning also reveals that the patient has observed no pattern indicating that the
symptoms occur only during the luteal phase. You also note that at the time of the
examination, when she presents with nervousness, GS is in the follicular phase of her
cycle.
She saw a physician assistant in a primary care practice regarding these symptoms. He
told her that he believes she has PMS. The patient does believe that her symptoms may
get worse at different times of the month, but she has never been able to keep track of
them long enough to know whether there is a specific cyclic pattern to these problems.
General lab tests were performed and were normal. Under the assumption that it is
PMS, he recommended a series of treatments, all of which have been unsuccessful, i.e.
birth control pills, progesterone suppositories, vitamin B6 supplementation, diuretics
and nonsteroidal anti-inflammatory drugs, specifically Ibuprofen and Naproxen
Sodium. She has taken all of these medications and has also tried to get more exercise
and “eat right.” She believes that the combination of being separated from her husband,
moving to a new town, and the stress of doing her job accurately has overwhelmed her.
She does not understand why the PMS has not improved and asks whether a
hysterectomy might be the solution.
Treatment:
Because the physical examination, thyroid function tests, electrolytes, liver function test
and a complete blood count are normal, you are confident that the patient does not
have any underlying medical conditions. You suggest to the patient that she may have
an anxiety disorder, perhaps generalized anxiety disorder. You initially start her on
Alprazolam, 0.25 mg, three times a day and suggest that she monitor her symptoms and
return in one week.
The patient returns in one week and reports significant improvement in her sleep
patterns, as well as her mental functioning. She feels much calmer. You reassure the
patient that there is no underlying medical problem and that she is not “going crazy,”
but appears only to have an anxiety disorder that can be treated successfully. You
explain to her that life stressors can exacerbate her underlying anxiety disorder.
You also recommend that she avoid caffeine and alcohol. Although she feels better, the
patient wishes to discontinue the medication to see if her lifestyle changes might make
a difference.
She returns 1 month later, and her symptoms have returned. You then initiate therapy
with Buspirone, 10 mg, three times a day, and explain to her that it will take 2 to 3
weeks for this medication to take effect. You also explain that it does not have any
sedating qualities and will not be habit forming. The patient returns 3 months later, at
which time she is functioning well and is quite comfortable with the current dosage of
Buspirone.
Teaching points:
NEOPLASIA
Clinical Case:
The uterus is enlarged, measuring 27 cm from the pubic symphysis. Fetal heart tones
are not auscultated by Doppler. She denies vaginal bleeding or passage of tissue from
the vagina. Vaginal exam is unremarkable.
Routine prenatal labs were unremarkable. She is Rh-positive. Quantitative beta HCG
levels were markedly elevated at 112,320 MICU/ml. TSH was low and further thyroid
testing revealed the patient to be mildly hyperthyroid.
Ultrasound showed the uterus to be enlarged, with multiple internal echoes and a
“snow storm” appearance. No fetus is noted. Ultrasound also showed enlarged multi-
loculated ovarian cysts bilaterally. Chest x-ray was normal.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 42 Gestational Trophoblastic
Neoplasia. Pages 411-417.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 43
Gestational Trophoblastic Neoplasia. Pages 486-494.
Gestational Trophoblastic Neoplasia (GTD)
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Gestational Trophoblastic Neoplasia (GTD)
Preceptor Handout
Clinical Case:
The uterus is enlarged, measuring 27 cm from the pubic symphysis. Fetal heart tones
are not auscultated by Doppler. She denies vaginal bleeding or passage of tissue from
the vagina. Vaginal exam is unremarkable.
Routine prenatal labs were unremarkable. She is Rh-positive. Quantitative beta HCG
levels were markedly elevated at 112,320 MICU/ml. TSH was low and further thyroid
testing revealed the patient to be mildly hyperthyroid.
Ultrasound showed the uterus to be enlarged, with multiple internal echoes and a
“snow storm” appearance. No fetus is noted. Ultrasound also showed enlarged multi-
loculated ovarian cysts bilaterally. Chest x-ray was normal.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 42 Gestational Trophoblastic
Neoplasia. Pages 411-417.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 43
Gestational Trophoblastic Neoplasia. Pages 486-494.
CLINICAL CASE 50
Vulvar Neoplasms
A 67-year-old woman presents with the complaint of a pruritic area on the right side of
her vulva. She has noticed this for about three months, and has used a variety of over-
the-counter creams, including imidazole and corticosteroid preparations, without
success.
Gynecological history:
She underwent an uneventful menopause at age 52. She tried hormone replacement
therapy for three years, which she finally discontinued because of irregular bleeding.
The bleeding stopped when she discontinued therapy. She has no other gynecological
complaints. She does have a history of abnormal Paps, including a conization at age 35.
Her last Pap was approximately 7 years ago.
The patient has a long-standing history of hypertension. She is presently taking a beta-
blocker and states that her hypertension is well controlled. She has no other medical
complaints.
Physical exam:
Laboratory:
Vulvar biopsy was performed, with removal of the entire lesion. Results were squamous
cell carcinoma of the vulva. Stromal invasion was less than 1 mm. Margins were clear of
tumor.
Management:
This is a Stage I lesion with a central location. Wide local excision with close
observation is appropriate management. For more advanced lesions, radical excision
with inguinal node dissection is utilized. This surgery has significant morbidity. The
surgical lymphadenectomy is bilateral with central lesions and ipsilateral for lateral
lesions. Adjuvant radiation therapy is frequently utilized.
Teaching points:
Squamous cell carcinoma typically occurs in menopausal women, pruritus is the most
common chief complaint. The most common type (86%) is squamous cell cancer as
with most cancers of the lower genital tract, is likely associated with oncogenic strains
of Human Papilloma Virus (HPV).
The malignancy behaves differently from the typical squamous cell carcinomas, which
occur on the face and torso and are associated with overexposure to sunlight. Inguinal
node metastases is common with more advanced lesions. Radical vulvar surgery and
inguinal lymphadenopathy carries high morbidity.
TEACHING CASE 51
Clinical Case:
Discussion Questions:
2. Which historical risk factors does this patient have for having cervical dysplasia or
for having cervical dysplasia progress to cervical cancer?
4. What would you recommend as the next step in the evaluation of this patient's
abnormal pap smear?
5. Would typing for the human papilloma virus aid in the management of this patient?
6. From a reproductive health perspective, how would you counsel this particular
patient about smoking cessation?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 44 Cervical Neoplasia and
Carcinoma. Pages 430-447.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 39 Cervical
Dysplasia and Cancer. Pages 447-458
Cervical Disease and Neoplasia
Preceptor Handout
Detection and treatment of pre-invasive lesions reduces the medical and social costs of, as
well as the mortality associated with, carcinoma of the cervix.
The APGO Educational Objectives related to this topic are the following:
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Cervical Disease and Neoplasia
Preceptor Handout
Clinical Case:
Discussion Questions:
2. Which historical risk factors does this patient have for having cervical dysplasia or for
having cervical dysplasia progress to cervical cancer?
4. What would you recommend as the next step in the evaluation of this patient's
abnormal pap test?
5. Would typing for the human papilloma virus aid in the management of this patient?
6. From a reproductive health perspective, how would you counsel this particular patient
about smoking cessation?
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 44 Cervical Neoplasia and
Carcinoma. Pages 430-447.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 39 Cervical
Dysplasia and Cancer. Pages 447-458
TEACHING CASE 52
Uterine Leiomyoma
Student Handout
Clinical Case:
Beta HCG is negative. CBC reveals hemoglobin of 10.3 and hematocrit of 31.2. Indices
are hypochromic, microcytic. Serum ferritin confirms mild iron deficiency anemia. Pap
smear is reported negative for malignancy, adequate for evaluation. Ultrasound shows a
large irregular mass, filling the pelvis and extending into the lower abdomen. The mass
does extend into the right side of the pelvis. There is mild hydronephrosis on that side.
The ovaries are not visualized. Endometrial biopsy reveals proliferative endometrium.
Discussion questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 45 Uterine Leiomyoma and
Neoplasia. Pages 448-454.
ACOG Practice Bulletin 16. Surgical Alternatives to Hysterectomy in the Management of Leiomyomas May
2000.
Uterine Leiomyoma
Preceptor Handout
Uterine leiomyomas represent the most common gynecologic neoplasm and are often
asymptomatic.
The APGO Educational Objectives related to this topic are the following:
D. List the indications for medical and surgical treatment of uterine leiomyomas
Clinical Case:
Beta HCG is negative. CBC reveals hemoglobin of 10.3 and hematocrit of 31.2. Indices
are hypochromic, microcytic. Serum ferritin confirms mild iron deficiency anemia. Pap
smear is reported negative for malignancy, adequate for evaluation. Ultrasound shows a
large irregular mass, filling the pelvis and extending into the lower abdomen. The mass
does extend into the right side of the pelvis. There is mild hydronephrosis on that side.
The ovaries are not visualized. Endometrial biopsy reveals proliferative endometrium.
Discussion questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 45 Uterine Leiomyoma and
Neoplasia. Pages 448-454.
ACOG Practice Bulletin 16. Surgical Alternatives to Hysterectomy in the Management of Leiomyomas May
2000.
TEACHING CASE 53
Endometrial carcinoma
Student Handout
Clinical Case:
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 46 Endometrial Hyperplasia and
Cancer. Pages 455-463.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 42 Uterine
Corpus Cancer. Pages 478-485.
Endometrial carcinoma
Preceptor Handout
The APGO Educational Objectives related to this topic are the following:
Clinical Case:
Discussion Questions:
Important to consider diagnoses that are common and those that are serious
Fibroids, polyps
Hormonally related bleeding
Endometrial hyperplasia or endometrial carcinoma
3. What risk factors does this patient have for endometrial carcinoma?
Obesity
Nulliparity
Late age at menopause
Infertility
Diabetes and history of gallbladder disease
Other risk factors this patient does not have include use of menopausal
estrogens and tamoxifen and a family history of genetically linked cancers
such as hereditary colon cancer and ovarian cancer
4. What factors are protective against endometrial cancer?
5. What are the next steps in the diagnostic work-up of this patient?
Ultrasound
Endometrial biopsy
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 46 Endometrial Hyperplasia and
Cancer. Pages 455-463.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 42 Uterine
Corpus Cancer. Pages 478-485.
TEACHING CASE 54
Ovarian Neoplasms
Student Handout
Clinical Case:
A 48 year old G3P3 woman comes to the office for a health maintenance exam. She has
no concerns. She is in good health. She had three normal vaginal deliveries and
underwent a tubal ligation after the birth of her third child 15 years ago. She has no
history of abnormal Pap smears or sexually transmitted diseases. Her cycles are
regular and her last menstrual period was 18 days ago. She is not taking any
medications. Her family history is significant for a maternal aunt who was diagnosed
with ovarian cancer at age 60. On examination, she has normal vital signs. Her heart,
lungs and abdominal exams are normal. On pelvic examination, she has normal
external genitalia, normal vagina and cervix. On bimanual exam, she has a slightly
enlarged uterus and a palpable right adnexal mass which is confirmed on the vagino-
rectal exam.
Discussion Questions:
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 47 Ovarian and Adnexal Masses.
Pages 464-476.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 40 Ovarian
Cancer. Pages 459-468.
Ovarian Neoplasms
Preceptor Handout
Adnexal masses are a common finding in both symptomatic and asymptomatic patients.
Management is based on determining the origin and character of these masses.
The APGO Educational Objectives related to this topic are the following:
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
Ovarian Neoplasms
Preceptor Handout
Clinical Case:
A 48 year old G3P3 woman comes to the office for a health maintenance exam. She has
no concerns. She is in good health. She had three normal vaginal deliveries and
underwent a tubal ligation after the birth of her third child 15 years ago. She has no
history of abnormal Pap smears or sexually transmitted diseases. Her cycles are
regular and her last menstrual period was 18 days ago. She is not taking any
medications. Her family history is significant for a maternal aunt who was diagnosed
with ovarian cancer at age 60. On examination, she has normal vital signs. Her heart,
lungs and abdominal exams are normal. On pelvic examination, she has normal
external genitalia, normal vagina and cervix. On bimanual exam, she has a slightly
enlarged uterus and a palpable right adnexal mass which is confirmed on the vagino-
rectal exam.
Discussion Questions:
2. How would your approach be different if the patient was postmenopausal at 62 years
of age?
3. You obtain an ultrasound which shows a 6 cm right complex ovarian cyst. What is
your differential diagnosis?
Need to discuss the differential diagnosis for an ovarian mass, benign and
malignant.
Benign:
o Functional cyst
o Endometrioma
o Serous/mucinous cystadenoma
o Gonadal stromal tumors
o Germ cell tumors (teratomas)
Malignant:
o Epithelial tumors (serous, mucinous, clear cell, endometrioid,
Brenner)
o Germ cell tumors (dysgerminoma, endodermal sinus tumor, immature
teratoma)
o Sex cord stromal tumors (Sertoli-Leydig, Granulosa)
4. What risk factors does this patient have for ovarian cancer?
5. List history and physical exam elements which help support or rule out the diagnosis of
ovarian cancer.
6. Assuming the mass is persistent and you need to surgically explore the patient,
describe the pre-operative, intra-operative and post-operative management of this
patient.
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 47 Ovarian and Adnexal Masses.
Pages 464-476.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 40 Ovarian
Cancer. Pages 459-468.
UNIT SIX:
HUMAN SEXUALITY
Case 1
At the conclusion of this exercise, the student will be able to provide a preliminary
assessment of patients with sexual concerns and make referrals when appropriate.
D.S.D. is a 29-year-old G2P1 who comes to see you because of decreased sex drive and
pain with intercourse. She reports that since the birth of her child about one year ago,
her sexual relationship with her husband never returned to normal. She does admit to
being very stressed out lately because she started a new job six months ago and she is
trying to balance it out with being a mother. She also reports being very tired most of
the time.
Physical exam:
Young woman in no distress who starts crying when asked about her relationship with
her husband. The rest of her physical exam is all normal.
Laboratory:
Hematocrit and TSH normal.
Assessment:
Decreased sex drive, possible depression
Plan:
Careful history and physical exam.
Rule out any possible underlying medical problems, e.g. hypothyroidism.
Counseling:
Possible referral to a therapist.
Discussion:
Careful history and physical exam need to be done to rule out any possible underlying
medical problem such as anemia, hypothyroidism or diabetes. Also need to rule out
substance abuse, such as smoking or alcohol, or any other medications that can affect
sexual function.
This patient most likely has underlying emotional problems and possible depression.
She needs to be counseled on marriage expectations in light of her exhaustion and
ability to cope with new and stressful responsibilities. Couple counseling might also be
helpful and consider referral to a sex therapist.
Teaching points:
1. Need to rule out any underlying medical conditions which can affect libido, such
as diabetes, hypertension, depression, or the presence of smoking or substance
abuse. Need to also check medications list for ones that can affect sexual
function.
Case 2
At the conclusion of this exercise the student will be able to discuss how a woman’s means
of sexual expression affects the detection and management of her health care problems.
L.W. is a 33-year-old G0 who comes to the office for health maintenance exam. Her
previous medical and surgical history is negative. She has regular menses, has never
had a history of abnormal Pap smears. Her last one was 2 years ago. She lives with Lisa,
her current partner of 6 months. She smokes 1 pack per day and has for the last 10
years. She does not use alcohol or any other drugs. She is on no medications. She has
no complaints and wants to know what screening measures she needs.
Physical exam:
Laboratory:
Pap smear normal
Assessment:
Healthy woman, smoker
Plan:
-History and physical exam
-Pap smear
-Counseling regarding smoking cessation, discuss exercise and calcium intake
-Discuss desires for fertility
Discussion:
This is a young healthy woman whose only issue is smoking. Her sexual orientation
does not put her at any additional risk for STD’s, but does not exclude her from
contracting a sexually transmitted disease. She should be counseled, like any other
patient, that she needs a yearly Pap smear. You also need to be sympathetic to lesbian
issues, so she is comfortable discussing any relationship problems.
Teaching points:
2. Lesbian women are less likely than are gay men to engage in promiscuous sexual
encounters and run less risk of HIV transmission. While contraception is not an
issue, protection from sexually transmitted disease is a concern and should be
discussed where relevant.
Sexual Assault
At the conclusion of this exercise, the student will be able to provide a preliminary
assessment and discuss management of patients subjected to sexual assault.
A 24-year-old woman was seen in the emergency department at 2:00 am for alleged
sexual assault. She reported that she was on a “blind date” and began heavy petting at
about midnight. This continued for quite some time, and the “date” would not stop his
advances. She stated that she had been held down while her clothes were removed and
then was forced to “have sex.” She was very tearful, distraught, agitated and admitted
that she had been drinking alcohol. The emergency department staff was very busy with
a number of other patients. The gynecologist finally arrived at 4:00 am, although the
patient had arrived at 2:00 am. No female assistant or “stand-by” could be found for
another hour, so the examination began around 5:30 am.
Physical exam:
Minor abrasions on the patient’s back and several fresh areas of ecchymoses were
noted on her upper arms and breasts. The sexual assault kit materials were used, and
specimens were obtained from the vagina, urethra, rectum and oral cavity for analysis
and culture. Fingernail clippings, hair brushings and acid phosphatase swabs from the
vaginal discharge were obtained. The vaginal discharge was examined and motile
sperm were noted on a wet preparation.
Laboratory: Cultures, swabs and blood work.
Assessment:
Sexual assault
Plan:
Careful history and physical exam
Specimen collection/sexual assault kit
Take photographs of any injuries
Fill out and sign sexual assault chain-of-custody form
Notify social services, the assault crisis center and the police
Arrange for proper follow-up
Discussion:
Rape has traditionally been defined by law as forcible vaginal penetration without
consent. However, this is changing in many states. Many states have redefined rape so
that both men and women can be either victim or perpetrator. Some states have
degrees of rape, others limit admissibility of a victim’s previous sexual conduct, and
others have limited the requirement that the victim’s testimony be corroborated by
other evidence. Reforms continue. This case exemplifies “date rape” case in which
consent for sexual intercourse cannot be presumed without a clear expression of
consent, and because of mere acquiescence to sexual intercourse.
Rape is a crime that is seldom witnessed. Therefore, it is very important that the
gathering of corroborating evidence during the medical examination be done in such a
way that prosecution can be undertaken. The history and physical examination should
be conducted within a standardized legal format. Most hospitals have sexual assault kits
for this purpose. The physician should use these instruments precisely and should
express no opinions, conclusions or diagnosis in the record. The record should describe
the physician’s findings and examination methods in detail.
Informed consent should be obtained before the examination that will allow
photographs and passage of information to authorities, as well as a routine
examination. There may be reporting requirements in the jurisdiction of your practice,
especially if the patient is a minor. The examination should involve general inspection
for signs of trauma, evaluation of external genitalia and a vaginal speculum
examination. Certain features are critical. Any external lesions should be photographed.
The external genitalia should be carefully inspected. Sexual dysfunction is common
among rapists, and failure to ejaculate or erectile failure may make internal vaginal
fluid specimens unhelpful. In such instances, signs of soft tissue trauma to the genitalia
may be the only corroborating evidence. Likewise, acid phosphatase assays from
vaginal secretions may be very helpful when the rapist has had a vasectomy and the
semen contains no sperm. Fifty percent of tests run 12 hours after intercourse show
acid phosphatase concentrations in the normal range, making the timing of the
examination important, as well. Blood serotyping and genetic screenings are becoming
important aspects of sexual assault evaluations.
All specimens should be collected in the presence of a witness and taken directly to the
pathologist. Anyone participating in this system of collection and transport must sign a
chain-of-custody statement to avoid mistakes or exchanges of specimens. Any break in
the chain of custody makes it impossible to prosecute a case. It is important for
physicians to be ready to testify in court if prosecution is attempted. Hearsay rules may
prevent evidence alone from the examination to be admitted, although this is less
common when evidence is properly labeled. This can be the first contact with the legal
system for the obstetrician-gynecologist. In this setting, the physician serves as a
patient advocate and an expert witness within the system, making it an ideal
introduction to law. Over time, proper legal management of a sexual assault evaluation
may be as therapeutic as appropriate medical management, which could include long-
term psychotherapy.
Teaching points:
1. In sexual assault cases, the physician has two clear duties: 1) medical
treatment of the patient; and 2) collection and preservation of evidence.
2. The evidence must be collected with care and completeness, and chain-of-
custody requirements must be maintained or such evidence may be
inadmissible in court.
3. Having available persons from social services who can provide immediate
counseling and emotional support in an emergency department setting is
often helpful.
CLINICAL CASE 57
Domestic Violence
At the conclusion of this exercise, the student will be able to provide a preliminary
assessment and discuss management options of patients subjected to domestic violence.
A.W. is a 25-year-old G4P3 woman who makes an appointment to consult you about her
“PMS.” She complains that she is “not herself” for several days before her period and
that she can’t stop crying. She snaps irritably at her husband, who is a “good provider
for [her] and for the children.” She doesn’t have her usual patience with the children,
aged 3 years, 2 years, and 8 months. She startles easily and is clumsy. Just last month,
she accidentally broke a favorite figurine her mother had given her. She thinks she
might have felt better when she took birth control pills, but her husband doesn’t think
she should take drugs that “interfere with natural functions,” especially with this PMS
problem. He doesn’t like IUDs, diaphragms or condoms, either. When you screen the
patient for depressive symptoms, she denies appetite disturbance. Her sleep is
somewhat fitful, but she has to keep an ear cocked to hear the children so that they
won’t disturb her husband, as “he has to get to work in the morning.” Her energy and
sex drive are not great, but she believes that’s pretty natural with three children. She
manages to keep up with them and the housekeeping. She enjoys seeing other people,
but doesn’t have much time for socializing.
Her husband, who has accompanied her to the appointment, confirms her account. He
says she “would be a great little wife and mother if it weren’t for this darned PMS.” He
remains in the examining room throughout the interview and general physical and
pelvic exams, holding his wife’s hand and patting her on the back from time to time. He
tells you that you shouldn’t worry about the cost of treatment because he wants his wife
to have whatever she needs.
Physical exam:
All normal, except a small bruise on A.W.’s right arm.
Laboratory:
Hematocrit and TSH normal.
Assessment:
Possible depression, protective husband, bruise on arm, possible domestic violence
Plan:
Careful history and physical exam
Rule out any possible underlying medical problems, e.g. hypothyroidism
Review previous medical records
Counseling
Possible referral to therapist or social worker
Discussion:
A.W.’s symptoms do seem to occur in the premenstrual phase. It is not clear whether
she meets criteria for major depression or dysthymic disorder as well, but since the
treatment for PMS is selective serotonin reuptake inhibitors (SSRIs), which are
antidepressants, you reason that you will treat the depression, if it is present.
After ordering a laboratory workup, you prescribe sertraline 50 mg/day. You also
arrange to have her previous medical records sent to your office. Prior to A.W.’s return
visit 2 weeks later, you review her records and notice that she has made numerous
visits to physicians with vague complaints of headaches and abdominal pains over the
years. She has also been seen in the emergency department for a succession of
lacerations and broken bones. Bruises were noted on these visits, but always explained
by the patient.
When A.W. appears for her visit, again accompanied by her husband, you ask the office
nurse and clerk to engage him in a lengthy discussion of insurance benefits. When he is
not present, you tell A.W. that you are glad to have the opportunity to speak with her
alone. She indicates that the medication has not made much of a difference in her
symptoms. You tell her that people sometimes have symptoms like hers when others in
their home are hurting them, and that you have noticed many injuries in her past
medical history. A.W. looks very frightened. You assure her that you are there to help
and that you will keep her statements strictly confidential. A.W. breaks down in tears
and tells you that her husband’s temper sometimes gets the best of him, and she says,
“He would kill me if he knew I had told anyone.” You assure A.W. that no one has the
right to hurt anyone and discreetly provide her with information about domestic
violence. After several visits in the company of her husband, A.W. comes alone one day
and tells you, “It took me a while to face the fact that I was being abused and to get up
the nerve to leave, but one day my husband hit our oldest daughter, and I realized I had
to get out. The kids and I are living with my mother now, and I am going to school so
that I can take care of us and make us a new life.”
Teaching points: