4 cases of pelvic mass are discussed .Adnexal mass invilves masses arisinf from ovary,fallopian tube,uterus,bowel and some miscellenious masses.USG is used to detect its size and the origin.Histopathological findings are diagnostic.
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
Case Report:Massive Ovarian Cyst in a Adolescent GirlTana Kiak
For benign tumours adhesion prevention strategies should be used. Surgical intervention should as much as possible be directed towards preservation of ovarian tissue. There is scarcity of published literature on this subject.
We need bigger studies to address the issue of how much fertility preservation is safely possible.Irrespective of indication for surgery, it is always preferable to attempt conservative, fertility sparing surgery in adolescents.
A case of an ovarian tumour pre-operatively thought to be malignant, which was per-operatively diagnosed as benign and later confirmed as a mucinous cystadenoma.
Ob-Gyn Department, BIRDEM-2 General Hospital, Shegunbagicha, Dhaka, Bangladesh
Case Report on Invasive Mole. Gestational Trophoblastic Neoplasia (GTN) encom...Niranjan Chavan
Gestational Trophoblastic Neoplasia (GTN) encompasses a suite of rare but significant gynecological malignancies arising from aberrant placental trophoblast cells. As medical professionals and researchers, our comprehension of GTN's complexities is crucial for accurate diagnosis and effective treatment. This introduction serves to illuminate the key features, diagnostic procedures, and treatment protocols associated with GTN, helping to navigate the intricate landscape of this disease.
Peripartum cardiomyopathy (PPCM) is a rare form of heart failure that occurs during the last month of pregnancy or within the first five months postpartum. It presents significant challenges in diagnosis and treatment due to its overlap with symptoms of normal pregnancy and postpartum changes. This condition varies in incidence across different racial groups and geographical locations, with a notable occurrence in the United States and southern India.
DR. NNC LAPAROSCOPY IN PREGNANCY IAGE VARANASI, 17TH MARCH 2024.pptxNiranjan Chavan
Our journey will navigate the evolution of laparoscopy in the context of pregnancy, detailing key milestones, breakthroughs, and advancements in technology and techniques. The presentation highlights how laparoscopy has revolutionized the diagnosis and treatment of conditions such as ectopic pregnancy, ovarian cysts and other gynecological disorders during pregnancy.
Optimising Delivery Of 1kg Fetus - Special Considerations.pptxNiranjan Chavan
After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth.
VACCINE IN WOMEN TOWARDS SDG 2030 DR.N N CHAVAN 10012024 AICOG HYDERABAD.pptxNiranjan Chavan
In our presentation today, we will unravel the transformative power of vaccines in women, aligning with the Sustainable Development Goals (SDGs) for 2030. By exploring the pivotal role of vaccinations, we aim to elucidate how they contribute to women's health, empowerment, and overall well-being. Through this lens, we envision a future where widespread vaccine access propels us closer to achieving the SDGs and ensures a healthier, more equitable world for women globally.
RRRR IN OBSTETRIC HEMORRHAGE 09012024 AICOG 2024 HEYDERABAD.pptxNiranjan Chavan
This presentation focuses on a critical aspect of maternal care: "Reducing Maternal Mortality through Rapid Response in Obstetric Haemorrhage" (RRRR). As we navigate through this presentation, let us collectively work towards advancing our understanding and application of RRRR in obstetric care to safeguard the well-being of mothers during childbirth.
Anemia is a condition in which the number of red blood cells and/OR their oxy...Niranjan Chavan
Anemia is a condition in which the number of red blood cells and/OR their
oxygen-carrying capacity is insufficient to meet the body’s physiological needs.
HELLP syndrome is a pregnancy complication. It is a type of preeclampsia. It ...Niranjan Chavan
HELLP syndrome is a pregnancy complication. It is a type of preeclampsia. It usually occurs during the third trimester of pregnancy. But it also can develop in the first week after childbirth
Guidelines & Identification of Early Sepsis DR. NN CHAVAN 02122023.pptxNiranjan Chavan
Here is a highly informative session on guidelines and identification of early sepsis as it is critical for timely intervention and improved patient outcomes.
PAST, PRESENT AND FUTURE IN OBGYN INFECTIONS 01102023.pptxNiranjan Chavan
Today, we face new infectious threats; but also benefit from advanced diagnostics and treatments. Looking ahead, it’s crucial to continue
adapting to emerging pathogens, implement stringent preventive measures, and
leverage cutting-edge technologies to ensure the safety and well-being of our patients in the ever-evolving landscape of obstetrics and gynecology.
Vaccination during pregnancy is crucial to protect both the mother and the developing baby. It helps prevent serious complications and ensures a healthier start in life. #VaccinateForTwo 🤰💉
Explore a comprehensive presentation on Invasive Cervical Carcinoma, shedding light on its causes, symptoms, diagnosis, treatment options, and preventive measures.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. PANELISTS
Dr.Amita Maheshwari
Dr. Susan Sodder
Dr. Shilpa Sankhe
Dr. Sarabjee Kaur
Dr. Kinjal Shah
Dr. Sachin Ajmera
Dr. Sachin Dalal
Dr. Bhumika Kotecha
Dr. Nidhi Gandhi
7. CASE 1
Mrs XYZ 45yr old P2L2 (FTND), with complaints of
Heaviness in abdomen
Irregular heavy menses
Dysmenorrhea , since 2 – 3 months
On Examination:
P/A – soft, non tender
P/S - cervix , vagina healthy
P/V – uterus bulky firm mobile, AV, soft to cystic mass 4x5
cm in right and posterior fornix separate from uterus. Left
fornix free and non tender.
P/R – bogginess felt anteriorly, rectal mucosa and
parametrium free.
Tumour Marker - WNL
8. Investigations:
USG Pelvis: solid, hypoechoic, well-circumscribed
right adnexal mass of size 3.6x4.6 cm
9. What is your diagnosis?
-Open to all the Panelist.
11. How will You differentiate between a
True and False Broad Ligament Fibroid ?
What will be relation of the Ureter to this
fibroid?
12. True Broad Ligament False Broad Ligament
Originates from the muscle fibres
normally found in the mesometrium (in
the round ligament, ovario-uterine
ligament, and the connective tissue
around the uterine and ovarian vessels)
Arises from the lateral wall of the
uterine corpus or of the cervix, and
bulges outward between the layers of
the broad ligament.
Ureter is medial to mass Ureter is lateral to mass
No groove felt between mass and
uterus
Groove felt between mass and uterus
13. What will be your approach in this
case?
Is there any role of ureteric stenting?
14. In this case ,
the right ureter was safeguarded by
dissection and enucleation could be
carried out rather easily.
17. CASE 2
A 14 years old girl , unmarried c/o
large abdominal mass
pain in abdomen
backache for 2-3 days.
Menstrual history : LMP : 27/12/11 . Menarche attained 5 days back. Patient had
bleeding for 5 days , changing 2 pads per day .
On Examination:
Per Abdomen: 34 – 36 weeks size mass arising from pelvis, Cystic in consistency .
Mobile from side to side. Smooth surface. Lower margin of the mass could not be
made out. Upper border of mass was 1-2 cm below the intercostal margin. Mass
was extending towards both the flanks.
Per Rectal: Lower margin of the mass felt. No involvement of the rectal mucosa.
Mass was free, mobile, non tender. No nodularity or induration felt.
18. Investigation:
Tumour markers-
Ca125- 19.1 u/mL
AFP- 1.06
B-HCG-< 1.2
CEA- 1. 34
USG Abdomen & Pelvis:
Uterus 6 x 3.1 x 2.7 cm. Normal endometrial echoes. ET 5 mm. B/L
ovaries not visualized. A large complex cystic lesion seen extending
from pelvis to epigastric region with multiple thick septae & multiple
echoes within noted. No vascularity noted within. The mass
displacing the bowels loops peripherally and uterus inferiorly. No
calcification or mass lesion within.
Impression: Mucinous Cystadenoma of the ovary of benign etiology.
19. CT Scan Abdomen (Plain & Contrast):
Large 18 x 15 x 11 cm sized, well defined , multiloculated ,
predominantly cystic , with multiple enhancing septae within
noted in the pelvis, extending into the lower abdomen, abutting
the anterior abdominal wall upto L1 – L2 vertebral level. No
calcification or solid component noted within the mass. The lesion
causing mass effect on the uterus displacing it postero – inferiorly
, on the urinary bladder displacing it inferiorly and on the
surrounding bowel loops displacing them peripherally. Mass
effect on lower ureter with resultant mild proximal b/l
hydroureter & hydronephrosis. The fat plane of this lesion with
the surrounding structures appeared well maintained. Rt ovary
seen separate from the lesion. Left ovary not appreciated on the
CT .
Impression: LT ovarian cyst adenoma of benign etiology.
20.
21. Intraoperative finding:
Patient underwent a successful ovariectomy with
partial salpingectomy on the Left side with removal of a
multi lobulated mucinous cyst adenoma.
About 300 cc of mucinous fluid was also aspirated from
the cyst.
Post operative course of the patient in the ward was
uneventful.
22.
23. Role of Tumour Markers?
What is ROMA test and its importance?
24.
25. ROMA: RISK OF MALIGNANCY ALGORITHM
Clinical Use:
Assess the likelihood that an ovarian mass is malignant in
women whose pre-surgical assessment did not indicate
malignancy.
Assess the need to refer the patient to a gynecologic
oncologist for treatment.
used as a supplement to the standard presurgical
evaluation to further assess the likelihood of malignancy
before surgery when the presurgical evaluation does not
indicate malignancy.
The pre-surgical evaluation should include
menopausal status,
physical examination,
transvaginal ultrasonography,
CA 125 concentration, and
family history of breast or ovarian cancer in a first-degree
relative.
26. It combines the results of human epididymis protein 4 (HE4)
enzyme immunometric assay (EIA), ARCHITECT CA 125 , and
menopausal status to generate a single numerical score that
correlates with the likelihood of malignancy being seen at
surgery.
The ROMA test is intended for use in women who meet the
following criteria:
Are over 18 years of age
Have an ovarian mass
Surgery is planned
Not yet referred to an oncologist
The ROMA test should not be used in women who have a
rheumatoid factor concentration >250 IU/mL.
27. Should we do Open Laparotomy knowing fully well
before hand that’s Malignant or Laparoscopic
Treatment ?
Management of Germ Cell Tumour?
Role of Neoadjuvant Chemotherapy?
Debulking or Cytoreductive Surgery ?
Followup & Survelliance in Stage 1A?
Fertility preservation surgery?
-.
28. Management of Germ Cell Tumour
Role of Neoadjuvant Chemotherapy
Debulking or Cytoreductive Surgery
Follow-up & Surveillance in Stage 1A
29.
30. Ovarian Germ Cell Tumours
Dysgerminoma
Endodermal sinus tumour
Embryonal Carcinoma
Polyembryoma
Choriocarcinoma
Teratoma-Mature/Immature
Immature – low grade/high grade
Surgical Principles
Suspect diagnosis
Pre-operative markers
Conservative- fertility preserving surgery
Staging-controversial- careful inspection of peritoneum, omentum,
contralateral ovary and nodes with washings and biopsies of
suspicious areas adequate
Unilateral oophorectomy with debulking if advanced stage
31. Surgery
Importance of staging in earl of staging in early disease
Fertility-sparing surgery often required
Can preserve uterus for future IVF, even if BSO
Debulking improves outcome
Chemotherapy
BEP
Bleomycin 20 U/m2 weekly x 9
Etoposide 100 mg/m2 days 1-5 q 3 weeks x 3
Cisplatin 20 mg/m2 days 1-5 q 3 weeks x 3
VAC
Vincristine 105 mg/m2 weekly x 12
Act D 0.5 mg days 1-5 q 4 weeks
Cytoxan 5-7 mg/kg days 1-5 q 4 weeks
VBP
Vinblastine 12 mg/m2 q 3 weeks x 4
Bleomycin 20 U/m2 weeks x 7, 8 on week 10
Cisplatin 20 mg/m2 days 1-5 q 3 weeks x 3
32. Germ Cell Tumour Surgery Chemotherapy
Dysgerminoma USO staging if
possible
BEP x 3 cycles if
stage II-IV
Endodermal sinus tumor Debulk preserve fertility BEP x 3-4 cycles
Embryonal carcinoma Debulk preserve fertility BEP x 3-4 cycles
Malignant teratoma Debulk preserve fertility BEP or VAC
x 3-4 cycles
Granulosa cell tumor USO if young o/w
TAH/BSO
BEP x 3-4 cycles
GnRH agonists for
advanced ds
Sertoli-leydig cell USO if young o/w
TAH/BSO
BEP or VAC
x 3-4 cycles
33. Surveillance:
Markers HCG AFP LDH CA125
1st year every 2 weeks x 6 m and then monthly x 6
2nd year monthly
3rd year every 3/12
4th year every 4/12
Subsequent years 6/12
Clinical exam
1st year monthly
2nd year every 2 months
3rd year every 3 months
4th year every 4 months
5-10 every 6 months
Imaging
Chest X ray alternate visits
Abdo-pelvic US every 3rd visit for first 2 years followed by annual
abdo-pelvic ultrasound subsequent years
34. Modalities of fertility preservation strategies
Strategy Modality
Preserving uterus and at least one
ovary
Conservative cancer surgery
Reducing radiation exposure to
ovary
Ovarian transposition
Reducing chemotherapy related
damage
Ovarian Suppression
Cryopreservation Freezing of embryos, oocytes and
ovarian tissue
35.
36. CASE 3
Mrs. ABC, 30/F, m/s 5 yrs came with the c/o
infertility
progressive cyclical dysmenorrhea since last 1 year.
Patient gives no h/o any menstrual irregularities.
On examination:
Per Abdomen: Soft, NO
guarding/rigidity/distention/tenderness
P/S: Cervix / vagina healthy
P/V:
Uterus bulky, Anteverted, Firm , restricted mobility
Right fornix free.
E/o bogginess in left and posterior fornix
measuring 5x5cm
USG – there is e/o left adnexal mass of 6x5 cm with thin
septations with no vascularity.
CA-125 – 105 IU/ml
Rest tumour makers - WNL
39. On diagnostic laparoscopy -
There is e/o dense adhesions in the pelvic
cavity.
uterus – restricted mobility.
POD obliterated.
Left tubo ovarian chocolate cysts seen with
dense adhesions to the bowel.
40. What is your diagnosis?
What are various management options and
what would be your approach in this case?
Future fertility and their management options ?
41. CASE 4
28 yr P2 L2 (FTND) with CuT 380A in situ with c/o
Dull lower abdominal pain with White foul smelling pv
discharge
Low grade fever. On and off since 6 months
Dyspareunia since 10 days
Menstrual history – menarche attained at 12 yrs. Past cycles
were regular/mod flow/painless/4/30 days
On Examination:
G/E: GC – average Pallor mild Febrile 38⁰Celscius
Pulse 100 b/min BP-90/60mm Hg
Per Abdomen-Soft, Tenderness in the left iliac fossa and
hypogastrium, No guarding, rigidity, distention, No Organomegaly.
42. Pelvic examination
Per speculum –
cervix shows sign of cervical erosion circumferentially around the external os
White discharge seen in the vaginal wall
On Bimanual Examination
Uterus anteverted, normal size
Left Fornix full, 4x4 cm cystic mass palpable
Bilateral fornices tender
Cervical motion tenderness +
Mobility restricted
43. Investigations –
Hb – 10.5 gm/dl/ TLC -20,000/cm, DLC-neutrophils 70,
lymphocytes-26,eosinophil-4
urine routine – pus cells 10 – 15/hpf
High vaginal swab sent
CA-125 – 42.5IU/ml.
CXR – NAD
USG abdomen and pelvis –
Uterus normal size , ET – 3mm
Right fallopian tubes and ovary normal.
Left fallopian tube enlarged , distended filled with low
echogenic material.
Tubal wall can be delineated.
There is e/o 4 by 3 cm multiloculated cystic left adnexal
mass
Rest USG - NAD
44. What is your diagnosis?
What are the causes Of PID?
Approach towards such patients?
Indication for In patient care?
Is there any role of Laparoscopy in this case?
Treatment of sexual partner and their follow up?
45. Pelvic Inflammatory Disease (PID) comprises a spectrum of
inflammatory disorders of the upper female genital tract,
including any combination of endometritis, salpingitis, tubo-
ovarian abscess, and pelvic peritonitis
• Sexually transmitted organisms, especially N. gonorrhoea
and C. trachomatis, are implicated in many cases
• However, microorganisms that comprise the vaginal flora
(e.g., anaerobes, G. virginals, Haemophilus influenzae,
enteric Gram-negative rods, and Streptococcus agalactiae)
also have been associated with PID
• In addition, M. [Mycoplasma] hominis and U. [Ureaplasma]
urealyticum might be etiological agents of PID
46. ACCEPTED PROPOSED
1. Menstruating teens 1. Low socio-economic status
2. Multiple sex partners 2. Early age of sexual activity
3. Prior H/O PID 3. Urban living
4. Sexually Transmitted Infection 4. High frequency of coitus
5. Non-use of barrier contraceptive 5. Use of IUCD
6. Cigarette smoking
7. Substance abuse
8. Douching
Risk Factors
48. Acute PID : Hospital admission
2. Patient meeting following criteria
a. Surgical emergencies (e.g., appendicitis) cannot
be excluded
b. Pt. is pregnant
c. Pt. does not respond clinically to oral
antimicrobial therapy
d. Pt. is unable to follow or tolerate an outpatient
oral regimen
e. Pt. has severe illness, nausea and vomiting, or
high fever
f. Pt. has a tubo-ovarian abscess
1. Judgment of the provider
49. Management:
relief of acute symptoms
eradication of current infection
minimalization of the risk of long term consequences
antibiotics
surgery (remove or drain a tubo-ovarian abscess)
50. Acute PID : Management
(Antibiotics for specific pathogen)
Organism Antibiotics
N. gonorrhea Cephalosporins, Quinolones
Chlamydia
Doxycycline, Erythromycin &
Quinolones (Not to cephalosporins)
Anaerobic organisms
Flagyl, Clindamycin &
in some cases to Doxycycline
ß-Haemolytic
streptococci.
&
E. coli
Penicillin derivatives, Tetracyclines,
and Cephalosporins.,
E. Coli is most often treated with
the penicillins or gentamicin
51. Inpatient treatment
Regimen A:
Administer cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h plus doxycycline 100
mg PO/IV q12h..
Continue this regimen for 24 hours after the patient remains clinically
improved, and then start doxycycline 100 mg PO bid for a total of 14 days.
Administer doxycycline PO when possible because of pain associated with
infusion. Bioavailability is similar with PO and IV administrations. If tubo-
ovarian abscess is present, use clindamycin or metronidazole with doxycycline
for more effective anaerobic coverage.
Regimen B:
Administer clindamycin 900 mg IV q8h plus gentamicin 2 mg/kg loading dose
IV followed by a maintenance dose of 1.5 mg/kg q8h. IV therapy may be
discontinued 24 hours after the patient improves clinically, and PO therapy of
100 mg bid of doxycycline should be continued for a total of 14 days. If tubo-
ovarian abscess is present, use clindamycin or metronidazole with doxycycline
for more effective anaerobic coverage.
52. Outpatient treatment
Regimen A:
Administer ceftriaxone 250 mg IM once as a single dose plus doxycycline
100 mg PO bid for 14 days, with or without metronidazole 500 mg PO bid
for 14 days. Metronidazole can be added if there is evidence or suspicion
for vaginitis or gynecologic instrumentation in the past 2-3 weeks.
Regimen B:
Administer cefoxitin 2 g IM once as a single dose and probenecid 1 g PO
concurrently in a single dose or other single dose parenteral third-
generation cephalosporin (ceftizoxime or cefotaxime) plus doxycycline
100 mg PO bid for 14 days with or without metronidazole 500 mg PO bid
for 14 days. Metronidazole can be added if there is evidence or suspicion
of vaginitis or gynecological instrumentation in the past 2-3 weeks.
53. Management :Surgery in Acute PID
Indications
1. Ruptured abscess
2. Failed response to medical treatment
3. Uncertain diagnosis
Type of surgeries
1. Colpotomy
2. Percutaneous drainage/aspiration
3. Exploratory laparotomy
Extend of surgeries
1. Conservation - if fertility desired
2. U/L or B/L Sal.-oophorectomy with/without
hysterectomy
3. Drainage of abscess at laparotomy
54. PID : Specialsituation
IUD users
Considerations
The risk for PID associated with IUD use is primarily confined to the first
3 weeks after insertion and is uncommon thereafter
Practitioners might encounter PID in IUD users because it’s a popular
method of contraception
Management
Evidence is insufficient to recommend the removal of IUDs
However
Caution should be exercised if the IUD remains in place, and close
clinical follow-up is mandatory. If improvement is not seen within 72
hrs of starting treatment then removal of IUCD is considered
No data have been collected regarding treatment outcomes by type
of IUD (e.g., copper or levonorgestrel)