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10 common gynacological problems

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  • 1. Case-study of Common Gynaecological Problems By El-Said Abdel-Hady, MSc, PhD, MRCOG, Mansoura University.
  • 2. Case-study      1-Vomiting during pregnancy. 2-Recurrent vaginal moniliasis. 3-Chronic pelvic pain. 4-Menorrhagia. 5-Postmenopausal bleeding.
  • 3. Case No 1       Primigravida, pregnant 7 weeks, presented with severe persistent vomiting. USS revealed twin gestational sacs. Pulse 120 beat/min. B.P 90/60 mmHg. Temp. 37.6 degree Celsius. Body weight 55 Kg.
  • 4. Case No 1  What would be your management?
  • 5. Case No 1   She was admitted to the Gynae ward and received IV fluid therapy, anti-emetics and antacids. FBC, urine analysis, LFT and KFT and electrolytes were normal apart from mild hyponatraemia (Na 128 mm/l).
  • 6. Case No 1  Initial improvement for few days, then relapse of persistent vomiting associated with hematemesis, severe hyperacidity and a tinge of jaundice.  Body weight was 51 kg.  What to do next?
  • 7. Case No 1    She was referred to GIT consultant and Upper GI endoscopy revealed gastritis. Naso-gastric feeding and IV antacids were given. Further investigations for liver enzymes, thyroid function tests, urea & electrolytes and level 3 abdominal and obstetric ultrasound were ordered.
  • 8. Case No 1    TFT revealed hyperthyroidism, and antithyroid medication was started. Obstetric ultrasound revealed viable twin pregnancy with CRL 8 weeks. Hyperkalaemia and hyponatremia were corrected.
  • 9. Case No 1   There was no significant improvement over the next few days and patient and family have requested termination of pregnancy. How to council?
  • 10. Case No 1   The patient was transferred to the high dependency unit for proper fluid and electrolyte monitoring. Discussions regarding selective fetal reduction versus termination of pregnancy continued.
  • 11. Case No 1    Gradual improvement was observed while on the HDU, body weight increased and the nasogastric tube was removed. She continued her medication for few days and then was returned to the ward. How to plan your management for the rest of pregnancy?
  • 12. 2-Recurrent vaginal moniliasis    35 years-old para 3, using IUCD for contraception. Complaining of white curdy vaginal discharge and vulval itching for 2 weeks. She has had similar episodes over the last 2 years.
  • 13. 2-Recurrent vaginal moniliasis  What would be your initial management?
  • 14. 2-Recurrent vaginal moniliasis    The IUCD was removed and a 3 night course of antifungal cream/pessary was prescribed. She experienced relief of symptoms for few days, then, She developed recurrence of intense itching and discharge.
  • 15. 2-Recurrent vaginal moniliasis  What to do next?
  • 16. 2-Recurrent vaginal moniliasis  Systemic antifungal was prescribed, to be repeated one course every month (just before menstruation) for 6 months.
  • 17. 3- Chronic pelvic pain    A 43 years old, para 4 presented to your clinic with chronic pelvic pain for 6 months. There was congestive dysmenorrhea but no dyspareunea. Gynaecological examination was entirely free and pelvic USS was normal.
  • 18. 3- Chronic pelvic pain  How to manage?
  • 19. 3- Chronic pelvic pain    She was referred to GIT, urology and orthopedic consultants and no cause was identified. Diagnostic laparoscopy was also normal. How to proceed?
  • 20. 3- Chronic pelvic pain   GnRH was prescribed for 3 months and she experienced some relief of pain. What to do next?
  • 21. 3- Chronic pelvic pain  TAH & BSO was done and histopathology revealed adenomyosis.
  • 22. 4- Menorrhagia     A 33 years-old para 0+0 presented with menorrhagia. Her periods are heavy and last for 10 days. USS revealed multiple uterine fibroids the largest was 5X4 cm. Her Hb was 7 gm%.
  • 23. 4- Menorrhagia  What would by your management?
  • 24. 4- Menorrhagia   Blood transfusion(4units) and haemostatics were given and her Hb became 11 gm%. She refused myomectomy as she was trying for conception.
  • 25. 4- Menorrhagia   The next few periods were heavy and her Hb became 8 gm% after few months. What to do next?
  • 26. 4- Menorrhagia    HSG revealed submucous myomas with patent tubes. Hysteroscopic resection of 2 submucus myomas bulging inside the cavity were carried out. No improvement of symptoms was noted over the next few cycles.
  • 27. 4- Menorrhagia    She was counseled and agreed for myomectomy. 8 myomas were removed and her periods became reasonable afterwards. Pregnancy occurred 6 months from myomectomy.
  • 28. 5-Postmenopausal bleeding    A-65 years old para o+o complaining of serosangneous vaginal discharge on and off for 2 months. She is diabetic and hypertensive. Her doctor reassured her that there was nothing to worry about, and gave her haemostatics and vaginal wash.
  • 29. 5-Postmenopausal bleeding  What is your feedback to the doctor’s comment?
  • 30. 5-Postmenopausal bleeding    She continued to bleed on and off for another 2 months, and went to see another doctor, who asked for USS. The USS showed endometrial thickness of 11 mm but no focal lesion. She was prescribed gestagens for 3 months.
  • 31. 5-Postmenopausal bleeding  What is your feedback to gestagen therapy in this situation?
  • 32. 5-Postmenopausal bleeding   Bleeding continued while on gestagen and she went to see a third doctor, who performed EUA and D&C. Histopathology revealed poorly differentiated adenocarcinoma of the endometrium.
  • 33. 5-Postmenopausal bleeding  TAH , BSO and vaginal cuff was done, followed by postoperative radiotherapy.
  • 34. Thank you.  El-Said Abdel-Hady.