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Obstetrics & Gynecology

Case Presentation

ZARIEH DAWN L. NOVELA


POST-GRADUATE INTERN
AMCM 2016-2017
Objectives

1. Present an interesting case during


OB-Gyn Rotation
2. Develop the knowledge and skills
necessary to diagnose, manage and
refer patient presenting with
patient’s chief complaint
3. Compare the important clinical
findings helpful in evaluating
patients with differential diagnoses
4. Share current information, articles
and/or researches regarding the
case
General Data

 B.S
 42 years old
 Filipino, Married, Roman Catholic,
Elementary school teacher
 2034 Leveriza St., Pasay City
 G2P0 (0010)
 Admission date: January 25, 2017

 Informant: Patient herself


 Reliability: 98%
Chief Complaint
On and off
hypogastric pain
for 1 month
Past Medical History

 (+) Previous hospitalization


 Dec 2014 – S/P Myomectomy
(AMCM)
 Undiagnosed thyroid disease
 (+) allergy – seafood, bagoong
 (-) hypertension
 (-) diabetes mellitus
 (-) bronchial asthma
 (-) tuberculosis
 (-) chronic liver disease
Family Medical History

 (+) Hypertension – mother


 (+) Thyroid disease - mother
 (-) Diabetes mellitus
 (-) Asthma
 (-) Cancer
 (-) obesity
Personal and Social History

 Elementary school teacher x 8 years


 Married x 2 years
 Non smoker
 Non alcoholic beverage drinker
 No prohibited drug use
Menstrual History

 M: 14 y/o
 I: Regular
 D: 3-4 days
 A: 3-4 pads/ day
 S: (+) dysmenorrhea, no meds
Gynecologic History

 Age of first intercourse: 36 y/o


 No. of sexual partners: 1 (husband)
 Birth control methods used: none
 STI: none
Gynecologic History

TVS Impression:
Nov 3, 2014 Bicornuate uterus vs septate (complete)
AMCM R subserous myoma
R anterior intramural myoma with subserous component
Abdominal Smaller posterior intramural myoma close to the serosa
enlargement Intact endometrial cavities
Normal looking R ovary
L ovary not seen

Findings:
There are 2 endometrial cavities joining at the region of internal os.
There is a big ovoid hypoechoic mass 88x63mm bulging out on R
anterolateral aspect of R fundal region. Its base 40mm.
There is a rounded hypoechoic mass 52.35mm on lower to midlevel
L of hemiuterus bulging into urinary bladder
A smaller mass 16x13.5mm is seen in the outer posterior wall,
upper level
Gynecologic History

TVS Impression:
April 11, 2015 Bicornuate uterus, single cervix
SJDDH Adenomyoma – anterofundal
Secretory endometrium
Normal ovaries with corpus luteum, R

Findings:
There is an irregularly bordered hypoechoic area anterofundally
(3.35x4.05.2.57cm)
There is fluid – culdesac
Obstetric History

 G2P0 (0010)
Year
1 March Complete abortion – 6 wks AOG
2016 No D&C
2 Present pregnancy

 PNMP: June 2016


 LMP: July 6, 2016
 EDC: April 13, 2017
 AOG: 28 6/7 wks
History of Present Pregnancy

4 wks • Pregnancy test positive


amenorrhea • Consult to local government hospital
• Multivitamins and Folic acid tab OD

• TVS:
• (+) whitish vaginal discharge, non-
Findings:
foul smelling; (+)2pruritus
Pregnancy endometrial cavities noted.
6 wks AOG •uterine
Isoxsuprine HCl 10mg
6 1/7wks, tab TID,
Live embryo Neo-
is in R endometrial cavity
Penotran vaginal
live, singleton supp. X
3 myomas:7 days
Multiple myoma, 1. Fundus: 1.9 x 1.5 mm
intramural 2. Ant. uterine wall: 2.3 x 1.9 mm
Bicornuate 3. Post uterine wall: 1.8 x 1.3 mm
uterus
TVS Imp:
Single, live, intrauterine pregnancy, 12 4/7 wks by CRL and
Oct 1, 2016 mean sac diameter with good cardiac activity
SJDDH
Normal both ovaries
Myoma nodule was described
>No subjective
No adnexal masses seen
complaints
>Normal results:
Findings:
CBC, UA, HbsAg,
Presence of bicornuate uterus is difficult to determine at present
VDRL
scan however well circumscribed hypoechoic structure on
anterior wall 3.89 x 3.31 cm

TAS Imp:
Dec 6, 2016 Pregnancy uterine 21 6/7 wks AOG by fetal biometry
AMCM Live singleton in variable presentation
Adequate amniotic fluid volume
Myoma nodules as described.
>No subjective
complaints Findings:
Myoma 1 – 16.4 x 28.4 x 25.9 mm – anterior wall, intramural
Myoma 2 – 32.1 x 26.4 x 32.8 mm – R lateral anterior
History of Present Pregnancy

• (+) Irregular mild uterine


25 wks contractions
AOG • Consult: Isoxsuprine HCl 10mg tab
TID x 3 days then PRN, hemarate FA
tab OD

TAS Imp:
Pregnancy uterine 25 6/7 wks AOG by biometry, complete
Jan 4, 2017 breech, live, singleton, normal amniotic fluid, male fetus,
multiple uterine myomas

Findings:
Uterine myoma 1 – 23 x 2o mm intramural, L upper anterior
2 – 21 x 18 mm intramural, R anterior
3 – 32 x 35 mm intramural vs subserous
component, R lower lateral
History of Present Pregnancy

• (+) Irregular mild uterine


24 wks contractions
AOG • Consult: Isoxsuprine HCl 10mg tab
TID x 3 days then PRN, hemarate FA
tab OD

Few hrs • Uterine contractions became more


PTA: frequent; q10-15 minutes
• Hypogastric pain, nonradiating,
28 wks 5/10, occurs with contraction
AOG • Consult
• ADMIT
Review of Systems

General (-) body weakness , (-) loss of appetite, (-) weight loss, (-) fever, (-)
easy fatigability
Integument (-) rashes, (-) jaundice, (-) wound, (-) pruritus, (-) pallor
HEENT (-)headache, (-)dizziness, (-)neck pain, (-) blurring/dimming of
vision, (-)epistaxis, (-)throat pain
Respiratory (-) cough and colds, (-) hemoptysis (-) pleuritic chest pain
Cardiovascular (-) cold perspirations (-) angina, (-) orthopnea, (+) palpitations
GIT (-) abdominal pain (-) abdominal distention, (-) constipation, (-)
hematochezia, (-) diarrhea, (-) melena
GUT (-) polyuria, (-) dysuria, (-) flank pain, (-) dysuria, (-) anuria, (-)
gross hematuria, (-) oliguria
Musculoskeletal/ (-) fracture, (-) weakness, (-) myalgia, (-) joint swelling, (-) joint
Extremities pain, (-) edema

Neurologic (-) seizure, (-) tremors, (-)syncope, (-)abnormal movements


Physical Examination

GENERAL SURVEY:
 conscious, coherent
 Ambulatory
 Not in cardiorespiratory distress

VITAL SIGNS:
 PR: 82 bpm
 RR: 21 cpm
 T: 36.6 0C (axillary)
 BP: 110/80 mmHg

 Ht: 147 cm
 Prepregnant wt: 50kg
 Current wt: 70.45 kg
 BMI: 23.15 (normal)
 Skin:
 Brown complexion

 no pallor, no cyanosis , no rashes, no


hypo/hyperpigmentation
 Good skin turgor

 Nails: no lesions or clubbing, no cyanosis

 HEENT:
 Anicteric sclerae, pink palpebal conjunctivae,
no tonsillophrayngeal congestion, no neck vein
engorgement, no cervical lymphadenopathy
 No neck mass/enlargement
 Chest/ Lung:
 (-) gross abnormalities such as lesions, masses,
deformities,
 Symmetrical chest expansion
 No retractions;
 No crackles and no wheezes

 Heart:
 Adynamic precordium.
 Point of maximal impulse is at 4th intercostal
space left anterior axillary line, no thrills, no
heaves
 Normal regular rate and rhythm, (-) murmur
 Abdomen:
 Globular
 (+) infraumbilical midline scar
 (+) linea nigra, (-) striae gravidarum, (-)dilated
veins, (-) discolorations
 FHT: 140s (RLQ)
 Fundic height: 29 cm
 EFW: 1355g
 Soft and nontender

 Genitourinary:
 Normal external genitalia
 IE: not done
 Extremities:
 No gross deformity

 (+) bipedal edema, Gr2

 full equal pulses


Salient features

 42 year old
 G2P0 (0010) PU 28 6/7wks AOG
 Hypogastric pain with uterine
contractions
 No watery vaginal discharge, no vaginal
bleeding, good fetal movement
 Bicornuate uterus on Ultrasound
 Multiple myoma on Ultrasound
Differential diagnosis

 Hypogastric pain with


Rule IN Rule OUT
Threatened preterm (+) uterine contractions
labor (+) hypogastric pain
(-) cervical changes

Preterm labor (+) uterine contractions Irregular mild


(+) hypogastric pain contractions,
No watery discharge/
vaginal bleeding
No cervical changes
Urinary tract (+) hypogastric pain No dysuria, flank pain,
infection fever, vomiting
Differential diagnosis

 Bicornuate uterus
Rule IN Rule OUT
Bicornuate uterus
Septate uterus
Didelphys uterus
Arcuate uterus
Admitting diagnosis

 Gravida 2 Para 0 (0010)


Pregnancy uterine 28 6/7 weeks
AOG, Threatened preterm labor;
Multiple myoma; Bicornuate
uterus
Course in the WARD
Potent
Day of Admission glucocorticosteroid
BP 110/80 IVF: D5LR IL x 8 hours
HR 81 DAT B-adrenoceptor
RR 21 Labs: CBC, Urinalysis agonist
Temp 36.1 Therapeutics:
FHT: 140s D5W 500cc + 4 amps Isoxilan to run at 20 gtts/min
Dexamethasone 6mg IV q12 x 4 doses
UA: ↑ WBC 10 Coamoxiclav 625mg tab BID x 7 days
Bacteria 45 Complete bed rest w/o bathroom privileges exc BM
FHT TID
Increase oral fluid intake, proper hygiene
Elevate feet using pillow for edema

7pm Decrease Isoxilan drip to 16 gtts/min


HR: 118
11 pm Iberet FA tab PO BID
Course in the WARD
Day of Admission
TAS Impression:
(1/25/17) Pregnancy uterine 29 1/7 weeks AOG by average fetal
biometry, cephalic, Live singleton
Normal amniotic fluid volume; Male fetus
Uterine myoma; cervix 36mm long, 11mm dilated

Findings:
There is 22 x 16 mm subserous myoma in midanterior region.
Other previously seen myomas are not visible at present
Course in the WARD
Hospital Day 1
BP 110/60 Continue management
HR 100
RR 22
Temp 36
FHT: 140s
Contractions- 1/15min
No vaginal bleeding
Good fetal movement
Hospital Day 2
BP 110/70 May go home.
HR 81 Take home meds:
RR 22 1. Coamoxiclav 625mg tab, 1 tab BID to complete 7 days
Temp 36.1 2. Iberet FA tab, 1 tab BI x 2 weeks then OD for next 2 weeks
FHT: 140s 3. Isoxilan 10mg tab, 1 tab TID x 3 days, then PRN
Contractions- 1/15min Follow up after 1 week
No vaginal bleeding
Good fetal movement
Final diagnosis

 Gravida 2 Para 0 (0010)


Pregnancy uterine 29 3/7 weeks
AOG, Threatened preterm labor;
Multiple Myoma; Bicornuate
uterus
Case Discussion
Uterine Malformation

 Abnormal development  Embryological


of the mullerian duct development is closely
during embryogenesis related to development
of urinary system.
 Epidemiology:  Anomalies in both may
 Mullerian anomalies: occur in ~25%
0.001 – 10% in general
population
 Uterine malformations -  References:

0.4-5%  1. Pui MH. Imaging diagnosis of congenital uterine


malformation. Comput Med Imaging Graph. 2004;28(7):425-
33.
 Bicornuate – 39% 2. Propst AM, Hill JA 3rd. Anatomic factors associated with
recurrent pregnancy loss. Semin Reprod Med.
2000;18(4):341-50.
 Septate – 34% 3. Golan A, Langer R, Bukovsky I, Caspi E. Congenital
anomalies of the müllerian system. Fertil Steril.
 Didelphic – 11 % 1989:51(5):747-55.

 Arcuate – 7 %
 Hypo- or aplastic – 4%
Embryology
Week 6

Week 10
v
Agenesis of both
ducts

Unilateral
maturation of on
mullerian duct

Absent or faulty
midline fusion of
ducts

Defective
canalization
Diagnosis

 Hysterosalpingography
 Sonography
 MRI
 Laparoscopy
 Hysteroscopy
Diagnosis

 Hysterosalpingography  MRI
 Fertility evaluation  Best imaging modality
 For uterine cavity and patency  Provides clear delineation of
assessment both internal and external
 Poorly defines external uterine uterine anatomy
contour  Renal and skeletal anomalies
 Contraindicated during may be evaluated
pregnancy  Precaution with pregnancy

 Sonography
 SIS – saline infusion  Laparoscopy and
sonography hysteroscopy
 Improves delineation of  Infertility evaluation
endometrium and internal  Assess for mullerian
uterine morphology anomalies, screen for
 Only in a patent endometrial endometriosis, tubal and
cavity uterine pathologies
 Contraindicated in pregnancy
Poor obstetric outcomes

Increased rates:
 ↓ cavity size  recurrent pregnancy
 insufficient musculature loss (RPL; 21–33%)
 preterm delivery
 impaired ability to
 Malpresentation
distend  IUGR
 abnormal myometrial  Cesarean section
and cervical function delivery
 Other: cervical
 inadequate vascularity incompetence,
 abnormal endometrial pregnancy-induced
hypertension and
development. antepartum and
postpartum bleeding
Unicornuate (Class II)

 Risk of ectopic
pregnancy
 Even in noncommunicating
horn, thru transperitoneal
sperm migration
 40% will have renal
anomalies
 Mngt:
 If pregnant: treated
medically or surgically
 If nonpregnant:
prophylactic excision of
horn that has cavity
Didelphys (Class III)

 Complete lack of fusion = 2


separate hemiuteri, cervices
and vagina
 Isolated or OHVIRA
 Suspected during pelvic
exam:
 Longitudinal vaginal septum and
cervices
Bicornuate (Class IV)

 Lack of fundal fusion = 2


hemiuteri, 1 cervix and
vagina
 Radiologic challenge
Septate (Class V)

 Resorption defect
 MRI and 3D to differentiate
from bicornuate
 Mngt: Hysteroscopic septal
resection
Arcuate (Class VI)

 Mild deviation from normally


developed uterus
 Low risk obstetric
complication than others
DES Reproductive abnormalities

 1960 – synthetic nonsteroidal


estrogen
 Used to treat pregnant women
for threatened abortion, preterm
labor, preeclampsia and diabetes
 Risk:
 Vaginal clear cell carcinoma
 Cervical intraepithelial neoplasia
 Small cell cervical cancer
 Vaginal adenocarcinoma
 Structural variations:
 Transverse septa
 Small uterine cavities
 T-shaped and irregular cavities
Summary and Conclusion
Summary and conclusion

 This is a case of a 42 year gravida 2 who had


miscarriage at previous pregnancy. She also was
previously diagnosed to have bicornuate uterus as an
accidental finding at ultrasound along with her myoma.

 Patient was presented to us with an on and off


hypogastric pain with uterine contractions for 1month.

 She is managed then as a threatened preterm labor


hence tocolysis was started. TAS was also done but the
bicornuate uterus cannot be appreciated, probably due
to enlarging conception that the uterus was stretched
out. Patient was discharged well at hospital day2.
Summary and conclusion

 Bicornuate uterus is the most common uterine malformation


where in there is failure of fusion of mullerian duct during
embryogenesis. Any uterine malformation are accompanied
with increased risk of several poor obstetric outcomes, such
as recurrent pregnancy loss and preterm labor.

 However, there are number of cases which resulted to


successful pregnancies once clinicians are aware of this

 Conclusively, we state that patient with bicornuate uterus


belong to high risk group and deserve a particular prenatal
care. Therefore it is of great importance for the clinician to
detect these abnormalities of the reproductive tract in early
stage by USG.
Thank you!

 References:
 Matthew Kaufman, Latha Stead, Jeane Holmes, Priti Schachel First
Aid for the Obstetrics and Gynecology Clerkship, Third Edition First
Aid Series 2010-16
 William’s obstetrics, 24th edition
 Beth W. Rackow and Aydin Arici , Reproductive performance of
women with mu ¨ llerian anomalies
 Propst AM, Hill JA 3rd. Anatomic factors associated with
recurrent pregnancy loss. Semin Reprod Med. 2000;18(4):341-
50.
 Golan A, Langer R, Bukovsky I, Caspi E. Congenital anomalies
of the müllerian system. Fertil Steril. 1989:51(5):747-55.