REFLECTIVE PRACTICE DOCUMENTATION MANAGEMENT OF PREGNANY

OF UNKNOWN LOATION

Mrs. Wasana was a 21 years old lady who has been married for one year duration
and she came from Polonnaruwa. She complained lower abdominal pain for two
weeks duration and had sixteenth weeks of period of amenorrhea. She had had
irregular cycles since her menarche and cycle length varied from 45 days to 60
days. On examinations her BMI was29Kg/M 2 and was not pale. Her pulse
ratewas78bpm-1 and blood pressure was 110/60mmHg.There was a mild diffuse
tenderness in the lower abdomen. On bimanual examination uterus was normal
in size. However, cervical motion tenderness and adenexial tenderness were
detected, especially in the right side.

Although urine HCG strip test was positive, Ultrasound scan did not show an
intrauterine pregnancy. Even though there was a detectable amount of free fluid
in the pouch of Douglas, adenexial masses were not detected. Working diagnosis
of ectopic pregnancy was made due symptoms and presences of free fluid .The
decision was made to perform a diagnostic laparoscopy.

On laparoscopic evaluation no ectopic pregnancy was detected. Bilateral tubes

and ovaries appeared to be normal. However, Pouch of Douglas filled with 100 ml
straw color clear fluid. She recovered well following surgery and followed up with
serial serum beta HCG assessment in 48hour intervals. Consecutive, serum beta
HCG value were 4170, 4300 and Subsequent Trans-vaginal ultra sound scan
done 4 days after laparoscopy revealed an intra uterine small gestational sac
.she was sent home on the 5th postoperative day and repeat ultra sound scan
done after2 weeks, confirmed the viability of the fetus.

What problem did you see and observe?

Patent presented with lower abdominal pain and positive Urine HCG. Initially,
there was no detectable intra uterine pregnancy and free fluid was seen in the
pouch of Douglas. Clinical features and ultra sounds evidence created the doubt
of possibility of ectopic pregnancy. Nevertheless, considering the fact that, she
was clinically stable, serial beta HCG assessment would have been a better
management option.

What did you do?

A decision was made to perform laparoscopy without considering option of doing

serial serum beta HCG assessment.

Justification of what you did

She had diffuse lower abdominal pain and cervical motion tenderness. In addition
to that, Initial ultra sound scan did not revealed an intra uterine pregnancy.
Furthermore, presence of free fluid created the doubt of ectopic pregnancy. As
laparoscopy is one of the popular surgical methods, which we carry out to
manage ectopic pregnancy in my unite, it was performed on this patient as well.

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What did you learn from this experience?

Ectopic pregnancy can have several clinical presentations. Provided that patient
clinically stable and criteria are fulfilled, there is a place for conservative
management with serial serum beta HCG measurements, before considering
surgical management.

What is done differently in other units: local and foreign?

This type of cases are managed as pregnancy of unknown location and serial
serum beta HCG is the management of choice, particularly if values is less than
1000iu/ml.

What would you do differently next time?

Serial serum beta HCG assessment in patients who are haemodynamically

stable, but suspected to have an ectopic pregnancy or exact location is not
known.

Evidence for suggesting these changes

1. Nice guideline-Ectopic pregnancy and miscarriages (CG 154)

2. Sivalingam VN, Duncun WC,Home AW. Diagnosis and management of
ectopic pregnancy. The journal of family planning & reproductive health
care, Oct2011; 37(4):231-240
3. Ramakrishnan K, Scheid DC. Ectopic pregnancy: Expectant management
an immediate surgery? The journal of family practice. 2006
June;55(06):517-520

Has the experience highlighted any deficiency in your training?

No

What learning needs did you identify from above?

Team involved in management of gyaenacology ward, should be aware of doing

serial beta HCG assessment 48 hourly intervals is the accepted practice in
modern management pregnancy of unknown location, provided that, patient is
haemodynamically stable.

Have you addressed these learning needs? If so how?

Yes, I have educated our senior house officers

Summary of discussion with trainer:

Comments of the trainer:

20


Comments of trainee:

Assessment: mark/grade..

Signature of trainer. Signature of

trainee..

Date..

Comment of external Assessors

Date ..

21
REFLECTIVE PRACTICE DOCUMENTATION MANAGEMENT OF SEVERE
ENDOMETRIOSIS

Describe the management of the selected cases

Mrs. Amali Rangika , 27years old lady, who has been married for 5 years ,came
from Kaduwela, was a known patient with severe endometriosis and admitted for
laparoscopic clearance of endometriosis. She was investigated for primary sub
fertility of four years and had had premenstrual build up and out lasting
dysmenorrhea and deep dyspareunia. However, she did not complain of
menorrhagia which can be associated with endometriosis.

She had undergone laparoscopic adhesiolysis and excision of right side ovarian
endometrioma in 2010and had repeat laparoscopic adhesiolyasis and tubal
patency test, six months after previous surgery. Even though ,she had severe
endometriosis, her both tubes were patent. Following this surgery, sub fertility
was planned to manage with ovulation induction and intra uterine insemination
of sperms. However, patient defaulted treatments and presented again with
severe abdominal pain in 2013. She underwent laparoscopic evaluation after
initial evaluation and found to have, extensive adhesions due to severe
endometriosis. Complete adhesiolysis was not carried out during the procedure
due anatomical reasons and continuous combined oral contraceptive pills had
been prescribed. Repeat laparoscopic evaluation was performed after this
admission and extensive adhesiolysis with excision of left sided endometrioma
were carried out. However, both tubes were patent to dye test.

Post operative recovery was uneventful and She was discharged, after
counseling and planned to do Intra uterine insemination following ovulation
induction, even though, the best management would be invitro fertilization in
this type of cases.

What problem did you see and observed?

Even though, with first laparoscopy correct diagnosis was made, subsequent
management was not satisfactory. patient would have been offered proper
counseling and directed to a proper management pathway of, either ovulation
induction and intra uterine insemination or in-vitro fertilization and no one
counseled her about poor reproductive outcome of this condition. Moreover
continuous combined oral contraceptive pills were started on her, though she
had reproductive wishes.

22
During the last four years she had undergone 3 laparoscopic evaluations, for the
same condition but,no one attempted for counsel her regarding suppression
therapy and assisted reproductive technique such as in vitro fertilization or
adoption ,which are more suitable for this couple.

What did you do?

Ovulation induction and intra uterine insemination were planned as feasibility of

other methods were remote for them

Justification of what you did

The couple was counseled about available suitable options as mention

previously. Considering their financial status, they chose to try with few cycles of
ovulation induction and intra uterine insemination. Therefore, it was offered to
them after explaining high chance of recurrence of disease during fertility
treatment.

What did you learn from this experience?

There are no evidence for repeated laparoscopic adhesiolysis for severe

endometriosis and chronic condition like this, need proper management plan
including appropriate counseling in the initial stage.

What is done differently in other units: local and foreign?

They offer the suppression therapy for endometriosis and do the assisted
reproductive method like IVF

What would you do differently next time?

At the beginning, proper counseling and suppression therapies will be offered,

provided that there are no immediate reproductive wishes and start assisted
reproductive method as early as possible.

Evidence for suggesting these changes

1. Green-top guide line 24-endometriosis, investigation and management

2. ACOG- pain management of endometriosis

Has the experience highlighted any deficiency in your training?

No

What learning needs did you identify from above?

23
All the doctors involved in management of gyaenacological ward, should be
aware about appropriate counseling and assisted reproductive methods
available for the management of endometriosis.

Have you addressed these learning needs? If so how?

Yes, all post graduate trainees and senior house officers were educated about it.

Summary of discussion with trainer:

Comments of the trainer:

Comments of trainee:

Assessment: mark/grade..

Signature of trainer. Signature of

trainee..

Date..

Comment of external Assessors

Date ..

24
REFLECTIVE PRACTICE DOCUMENTATION-PERIPARTUM HYSTERETOMY

Describe the management of the selected cases

Mrs. Fathima Rizna, 29 years old, in her second pregnancy and had booking visit
at period of gestation of 12 weeks . Her previous pregnancy had uncomplicated
antenatal period, though it ended up as an emergency lower segment caesarean
section due to fetal distress. Birth weight was 3.1kg.At booking visit her dates
were confirmed by using crown rump length. She had offer shared care and
antenatal period was uneventful.

She was admitted at the period of gestation of 39 weeks and 6 days with
complaining of abdominal pain for one day duration. As she was counseled
regarding the vaginal birth after caesarean section in antenatal follow up and she
gave consent for vaginal birth after caesarean section. On examination growth of
the baby was adequate for period of gestation. Estimated fetal weight was 3.1
according to the ultra sound scan.

Following day she went into active labour in the morning and artificial rupture of
membrane done due poor progression however, it was not satisfactory even
7hours after the onset of labor. Therefore, decision was made to do an
emergency caesarean section. During the caesarean section it was noticed
lateral extension of the uterine incision. But person who did the caesarean
section was managed to achieve hemostasis at that time and closed the
abdomen. Six hour after caesarean section it was noticed that anuria for 2 hours,
severe abdominal tenderness, difficulty in breathing in lying position, clinically
pallor, pulse rate of 123bpm-1 and blood pressure of90/50mmHg, tachypnea and
dullness on the right flanks. No significant per vaginal bleeding was noted. Ultra
sound scan of the abdomen suggested 100cc free fluid right side of the abdomen
and uterine cavity was empty. All the detail raised the possibility of internal
bleeding and decided for a reopening.

In the laparotomy there was a large hematoma in right broad ligament, and
extended through para-colic gutter, up to lower border of the liver. Therefore, it

25
was decided to go for total abdominal hysterectomy.3 pints of blood were
transfused. Postoperative recovery was uneventful.

What problem did you see and observe?

During the suturing of uterine wall angle of right side of caesarean section had
been missed by the surgeon and that cause continuous bleeding and which
cause collection of blood in broader ligament.

During the reopening there was no attempt to preserve uterus by trying to find
the bleeding point and ligate it instead of total abdominal hysterectomy.

What did you do?

total abdominal hysterectomy was performed

Justification of what you did

There was large hematoma in the right side of the abdomen and finding of
bleeder is difficult task. Furthermore patient was haemodynamicaly unstable.
Therefore, it was decided to do a total abdominal hysterectomy.

What did you learn from this experience?

Importance of proper post-operative monitoring and Importance of catching the

angle correctly during the suturing of uterine incision at caesarean section. If
there is any doubt about it, juniors should always seek the help of the
experienced persons.

What is done differently in other units: local and foreign?

Try to preserve the uterus by identifying and ligating it if possible.

What would you do differently next time?

Always ask for senior help in difficult caesarean sections

More effort to preserve uterus

Evidence for suggesting these changes

1. Lovina S.M, Machado. Emergency peripartum hysterectomy: incidence,

indications, risk factors and outcome. North American journal of Medical
Sciences, Aug 2011; 3(8):358-361

Has the experience highlighted any deficiency in your training?

No

What learning needs did you identify from above?

The entire doctors who are involved in obstetrics management should aware
about how to suture it when uterine incision extends during the caesarean

26
section. Also they should have aware that when to seek help to prevent the
adverse outcome.

Have you addressed these learning needs? If so how?

We have conducted the risk management meeting in our unit and discuss the
strategies to prevent these events in the future.

Summary of discussion with trainer:

Comments of the trainer:

Comments of trainee:

Assessment: mark/grade..

Signature of trainer. Signature of

trainee..

Date..

Comment of external Assessors

Date ..

27
REFLECTIVE PRACTICE DOCUMENTATION- MANAGEMENT OF AN ECTOPIC
PREGNANCY

Mrs. G Samaranayaka a 35 year old patient got admitted with worsening right
sided abdominal pain for 1 day duration. She has undergone In- vitro fertilization
due to primary subfertility 8 weeks back, and has had per vaginal bleeding after
2 weeks of IVF. Serum beta HCG levels done at that time has revealed values of
15,19,30 iu on serial 48 hour measurements taken. Ultrasound has not revealed
any intra uterine or extra uterine pregnancy and she has been discharged with a
diagnosis of complete miscarriage. She has had mild intermittent bleeding after
that and presented to us 8 weeks after the IVF with worsening right sided
abdominal pain.

She has had regular menstruation previously with no heavy menstrual bleeding
or dysmenorrhea and she has underwent 6 intrauterine inseminations due to
male factor subfertility. She did not have any significant past medical history and
she has undergone a laparoscopy and tubal patency test 1 year back.

On examination she had mild pallor with a tachycardia, blood pressure was
normal and on vaginal examination cervix was firm, os was closed, uterus
retroverted and bulky with cervical motion tenderness.

Urine HCG was positive. Ultrasound on admission revealed a uterus with 15 mm

endometrial thickness with a right sided irregular adenexial mass and small
amount of free fluid in pouch of Douglas. Serum beta HCG done on admission
was 480 iu. Decision was made to perform laparoscopy and during laparoscopy
she was found to have right sided leaking tubal ectopic and underwent
salphingectomy.

28
What problems did you see and observe?

35 year old patient with primary subfertility, presented with abdominal pain 8
weeks after IVF.

Suspected ectopic pregnancy with a beta HCG level of 480 iu

What did you do?

Decision was made to perform diagnostic laparoscopy.

Justification for what you did.

Although the beta HCG level was 480 patient was symptomatic and she had free
fluid in pouch of Douglas during the ultrasound.

What did you learn from this experience?

Beta-hCG levels alone cannot differentiate between ectopic and intrauterine

pregnancy, and serial beta-hCG levels that do not increase appropriately in a
woman with suspected ectopic pregnancy are only 36 percent sensitive and
approximately 65 percent specific for detection of ectopic pregnancy. ruptured
and unruptured ectopic pregnancies have been identified at beta-hCG levels less
than 100 mIU per mL (100 IU per L) and greater than 50,000 mIU per mL (50,000
IU per L).1

What is done differently in other clinical units: local and foreign?

Pregnancy of unknown location is diagnosed when an initial upper level of serum

HCG of 1000-1500 obtained with no ultrasound evidence of intrauterine or
ectopic pregnancy.

Expectant management is an option for clinically stable asymptomatic women

with an ultrasound diagnosis of ectopic pregnancy and a decreasing serum hCG,
initially less than serum 1000 iu/l.

29
Expectant management is only be used for asymptomatic women with an
ultrasound diagnosis of ectopic pregnancy, with no evidence of blood in the
pouch of Douglas and decreasing hCG levels that are less than hCG 1000 iu/l at
initial presentation and less than 100 ml fluid in the pouch of Douglas.

Patients who dont have significant pain, un ruptured ectopic pregnancy with an
adenexial mass smaller than 35mm with no visible heart beat and serum HCG
less than 1500 iu can be considered for medical management with methotrexate.

Women who are unable to return for follow up or have any of the following

Ectopic pregnancy and significant pain

Ectopic pregnancy with an adenexial mass of 35mm or larger

Ectopic pregnancy with a visible fetal heart beat on ultrasound

Ectopic pregnancy and a serum hCG level of 5000iu or more

are offered surgery as the first line treatment.

What Evidence influenced you in suggesting these changes?

Ectopic pregnancy and miscarriage: diagnosis and initial management in

early pregnancy of ectopic pregnancy and miscarriage. NCC-WCH guideline
December 2012.

Marie A, Potter B, diagnosis and management of ectopic pregnancy. Am

Fam Physician. 2005 Nov 1;72(9):1707-1714.

RCOG guideline 21, The management of ectopic pregnancy

Has the experience highlighted any deficiency in your training?

No

What learning needs did you identify from above?

Every doctor involved in management of early pregnancy complications should

be educated about diagnosis and management of ectopic pregnancy

Have you addressed these learning needs? If so how?

Learning session on ectopic pregnancy management was conducted. All post

graduate trainees, senior house officers and junior house officers were
participated.

30
Summary of discussion with trainer:

Comments of the trainer:

Comments of trainee:

Assessment: mark/grade..

Signature of trainer. Signature of

trainee..

Date..

Comment of external Assessors

Date ..

REFLECTIVE PRACTICE DOCUMENTATION-MANAGEMENT OF A PATIENT

WITH ANOVULATION

Mrs. Jayani Rajika, a 25-year-old house wife, who is married for 9 months
presented with secondary amenorrhea for 7 months and fertility wishes.
She has attained menarche at 14 years of age and had regular
menstruation since then with no history of heavy menstrual loss or
dysmenorrhea. She had underwent laparoscopic left sided salpingectomy
for left sided tubal ectopic pregnancy 7 months back and has had absent
menstruation since then. She did not have a history of excessive stress,
weight loss, eating disorder or any headache or visual symptoms. She did
not have any nipple discharge, cyclical abdominal pain or symptoms of
hypothyroidism. She did not have any significant medical history or
surgical history other than the laparoscopy.

On examination her body mass index was 29, she had secondary sexual
characteristics, she did not have any features of hirsutism, acanthosis,

31
goiter and rest of the general examination and systemic examination did
not reveal any significant findings.

Speculum examination revealed a healthy cervix, on bimanual

examination cervix was firm, os closed, and uterus anteverted.normal size
and there were no adenexial masses. Transvaginal ultrasound scan
revealed an anteverted uterus with trilaminar endometrium and bilateral
ovaries had multiple follicles (9, 8) ranging from 4-10 mm arranged
throughout the stroma of ovary with a normal ovarian volume.

A diagnosis of polycystic ovarian syndrome was made and patient was

given progesterone to induce menstruation with a plan of ovulation
induction from second day of menstruation. Day 02 FSH, LH, prolactin and
TSH were done. Investigations revealed a FSH level of 8.6 uIU/ml, LH level
of 8 uIU/ml, prolactin level of 915 uIU/ml and a TSH level of 5.8 uIU/ml.

On day 8 of the cycle, patient was reviewed with above investigations and
the transvaginal scan did not reveal any lead follicles. Diagnosis was
revised and a diagnosis of multicystic ovaries due to hypothyroidism was
made and the patient was referred to endocrinologist to start on thyroxin
therapy

What problems did u see and observe?

Incorrect diagnosis of polycystic ovary disease in a patient with

hypothyroidism and multicystic ovaries

Ovulation induction without correction of hypothyroidism, which by itself

will correct the anovulation with thyroxin treatment.

What did you do?

Gave her a progesterone challenge to induce menstruation and ovulation

induction was started with second day of the cycle while waiting for day
Day2 FSH, LH, Prolactin and thyroid hormone levels.

Justification of what you did?

According to her history and examination the patient did not have
symptoms of hypothalamic or pituitary cause of amenorrhea.

Also she had well oestrogenised endometrium and multiple immature

follicles progesterone challenge was given to exclude outflow tract
obstruction.

Although patient was 25 years old and subfertility treatment was started
with ovulation induction as the initial running diagnosis was polycystic
ovary syndrome.
32
What did you learn from this experience?

Anovulation in a patient with secondary amenorrhea and multiple

immature follicles in the ovary is not always due to polycystic ovary
disease

Polycystic ovary disease is diagnosed by the Rotterdam criteria when 2

features are present from following three criteria.

Oligomenorrhoea/amenorrhea
Hyperandrogenism (clinical or biochemical)
Polycystic ovaries on ultrasound (ovary with 12 or more
follicles measuring 2 - 9 mm in diameter or increases ovarian
volume > 10cm3
Of which this patient had amenorrhea and ultrasound findings of less than
12 follicles and her ovarian volume was also normal. Furthermore, overt as
well as subclinical hypothyroidism both can give rise to multicystic ovaries
and anovulation.

What would you do differently next time?

I will not be diagnosing polycystic ovary syndrome off handedly and will
be using the Rotterdam criteria to diagnose polycystic ovary syndrome will
keep in mind that hypothyroidism associated with multicystic ovaries is an
another cause for anovulation when working out differential diagnosis for
a patient with anovulation.

Evidence and justification

Adam H Balen. Polycystic ovary syndrome, A guide to clinical

management.
Richard S. Legro et al. diagnosis and treatment of polycystic ovary
syndrome. An endocrine society clinical practice guideline, Journal of
Clinical Endocrinology & Metabolism, December 2013, JCEM jc.20132350.

Has this experience highlighted any deficiencies in your training?

No

What learning needs did you identify from above?

That I need to carry out more case based discussions in the future

Have you addresses these learning needs? If so how?

33
I did a case based discussion with my trainer and discussed this case at
the monthly clinical meeting at Sri Jayewardenepura General Hospital
where I was able to get inputs from other specialties

Summary of discussion with trainer:

Comments of the trainer:

Comments of trainee:

Assessment: mark/grade..

Signature of trainer. Signature of

trainee..

Date..

Comment of external Assessors

Date ..

34
REFLECTIVE PRACTICE DOCUMENTATION-MANAGEMENT OF AN OVARIAN
MALIGNANCY

Mrs. P Roopasinghe, 80 year old patient presented with right sided

abdominal pain, abdominal distension associated with loss of appetite and
loss of weight for three months duration. Her bowel habits were normal,
she did not have vomiting or regurgitation. Other than increased
frequency of urination, she did not have any urinary symptoms or
hematuria.
She had difficulty in breathing on supine position, there was no exertional
dyspnea or chest pain. She did not have any significant past medical
history. She had undergone vaginal hysterectomy and repair 8 months
back and the histology revealed a benign endometrial polyp in a
background of atrophic endometrium with no evidence of malignancy. She
did not have any history of allergy.
On examination she was not pale, not icteric and there was no ankle
oedema. She was haemodynamically stable. Respiratory system
examination was also normal. On abdominal examination she was found
to have gross ascites with large abdomino pelvic ill-defined mass.
Ultrasound showed mass lesion in the left side of the pelvis most likely
arising from the ovary. Contrast CT abdomen+ pelvis showed metastatic
involvement of the peritoneum and omentum associated with ascites with
diaphragmatic and small bowel deposits. Her CA 125 level was 2400 and
routine preoperative investigations were normal. After discussing
thoroughly with the patient and relatives about the risks and outcome of
the surgery, decision was made to perform primary debulking surgery as
patient did not give consent for biopsy of the lesion and neoadjuvant
chemotherapy.
Patient underwent primary debulking surgery and was found to have
stage 1V ovarian malignancy and maximum debulking was done.
Patient was put to intensive care unit but on post op day two patient went
in to multiorgan failure due to systemic inflammatory response and in
spite of resuscitation patient succumb to death two days after surgery.

What problems did you see and observe?

80 year old patient with stage 1V ovarian malignancy not willing to
undergo neoajuvant chemotherapy.
What did you do?

Prepared the patient for primary debulking surgery with adjuvant therapy

35
Justification for what you did.

The overall five year survival for stage 111 to 1V ovarian carcinoma is 30
to 40 %. As the survival of patients with primary debulking surgery is
shown to be better than those with who unerdgo chemotherapy alone
decision was made to perform primary debulking surgery.

What did you learn from this experience?

Regarding the age and overall condition of the patient, biopsy and neo
adjuvant therapy would have been a better option under the
circumstances.

What is done differently in other clinical units: local and foreign?

Primary cytoreductive surgery is advocated for advanced ovarian

carcinoma unless it is considered by preoperative assessment that it
would be difficult to debulk the tumor to no macroscopic residual
disease, either due to the location or extent of disease, or because
the resultant morbidity would be considered too great.
When primary cytoreductive surgery is not feasible neo adjuvant
chemotherapy should be considered after obtaining tissue biopsy by
radiologically guided biopsy or laparoscopic tissue biopsy.

What would you do differently next time?

Patient selection will be individualized.

I will make sure to counsel the patient considering all following facts
the stage of the disease, treatment options and prognosis

how to manage the side effects of both the disease and its
treatments in order to maximize wellbeing

sexuality and sexual activity

fertility and hormone treatment

symptoms and signs of disease recurrence

genetics, including the chances of family members developing

ovarian cancer

self-help strategies to optimize independence and coping

where to go for support, including support groups

36
 How to deal with emotions such as sadness, depression, anxiety and
a feeling of a lack of control over the outcome of the disease and
treatment.

What Evidence influenced you in suggesting these changes?

Chemotherapy or upfront surgery for newly diagnosed advanced ovarian cancer; results
from the MRC CHORUS trial. J clin oncol 31,2013 (suppl:abstr550)
Nice guidelines (CG122)

Has this experience highlighted any deficiencies in your training?

No, I learned the management options of advanced ovarian carcinoma from this experience

Has this experience highlighted any deficiencies in your training?

No

What learning needs did you identify from above?

That I need to carry out more case based discussions in the future

Have you addresses these learning needs? If so how?

I did a case based discussion with my trainer and discussed with post
graduate trainees

Summary of discussion with trainer:

Comments of the trainer:

Comments of trainee:

37
Assessment: mark/grade..

Signature of trainer. Signature of

trainee..

Date..

Comment of external Assessors

Date ..

38