Case Presentation

John Christopher Luces

Maureen Betty Braga
Michael Lapasaran
M i k e e To n i S u n g a
PGI Camille Uy
Post Graduate Interns
CASE OVERVIEW
E.L.
51 years old, Female
Married, Roman Catholic
Tungkalan, Toril, Davao City

CC: Vaginal Bleeding

 History of Present Illness
2 months PTC:
- patient had profuse vaginal bleeding
5 napkins/day x 1 week
Sought consult in this institution and was subsequently
admitted
Work up was done: Endometrial Sampling and
Transvaginal UTZ
- Patient became anemic 3 units of PRBC transfused
 Past Medical History
- After correction of anemia patient was discharged
and was advised for surgery

Home medications:
MTV + FeSO4 1 tab OD x 1 month
Tranexamic acid 500 mg/tab prn for bleeding
OPD follow-up for OR scheduling
 History of Present Illness
1 Day PTC:
Patient started having vaginal bleeding
Used up 3 diapers and 5 napkins
Associated with crampy hypogastric pain
rated as 5/10
 Day of consult:
Same symptoms persisted thus sought consult
 Past Medical History
No previous surgery
No trauma
(-) Hypertension
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Thyroid Problems
(-) Cardiac problems
(-) Renal Problems
 Family History
No Family History of:
Stroke
Heart disease
Diabetes mellitus
Tuberculosis
Cancer
Hypertension
Asthma
 Personal/ Social History
Civil Status: Married
Occupation: Farmer
Educational Profile: HS graduate
Lifestyle habits:
Non-smoker
Non-alcoholic beverage drinker
No history of substance abuse
 OB-GYNE History
LMP: May 11, 2017
PMP: April 10, 2017
Menarche: 13 yo
Menstrual Cycle: Regular (28 days) x 4 days duration x soaking 3
regular pads per day (+) dysmenorrhea

Coitarche: 27 years old, 1 sexual partner

No history of contraceptive use
No history of Sexually transmitted infections
 Obstetrical Score
G2P2 (1001)

Pregnancy Pregnancy Year Gestation Sex Birth Present Complication

Order Outcome/ Completed Wt. Status
Delivery

G1 FDIU 1999 26 weeks - - Dead -

G2 CS delivery 2011 38 weeks Male 2800g Alive None

(Full Term)
 VITAL SIGNS AND ANTHROPOMETRICS

ER Normal Value
BP 110/80 90/60 mm/Hg to 120/80 mm/Hg
Temp 36.7 36.5 37.6
Pulse Rate 107
60-100
(tachycardic)
Respiratory Rate 24 12-18
Weight 43 kg
Height 139 cm
BMI 22.26 18.5 to 24.9
 Physical Exam

General Survey:
ambulatory, coherent, oriented, responsive pale, not in
respiratory distress, thin features, fair-colored skin

Skin and Integument: skin is brown smooth, warm to touch.

(+) pallor, no cyanosis. No rashes and skin lesions noted
 HEENT:
Head: normocephalic, hair dark brown and evenly distributed
Eyes: anicteric sclerae, pale conjuctiva, pupils equally round and
reactive to light and accommodation
Ears: intact pinna, no deformities, able to hearing and respond when
name is called
Nose: pink nasal mucosa, midline septum, no sinus tenderness, no
polyps
Mouth: moist, smooth and pinkish oral mucosa, no ulcers or dental
caries, not inflamed tonsils, no exudates
Neck: no neck vein engorgement, no cervical lymphadenopathies, no
masses
 Thorax and lungs
Inspection: symmetrical chest expansion
Palpation: no tenderness nor masses
Percussion: Resonant on all fields
Auscultation: Bronchovesicular breath sounds
 Heart
Inspection: No pulsations
Palpation: PMI at 5th ICS
Auscultation: tachycardic, regular rhythm
 Abdomen
Inspection: flat, umbilicus midline
Auscultation: normoactive bowel sounds
Palpation: (+) hypogastric mass 7x 6 cm, no
organomegaly
 Pelvic Examination
INSPECTION
Grossly normal external genitalia
Vulva:
(-) lesions
(-) swelling
(-) erythema

SPECULUM EXAM
pinkish, smooth, midline, scanty, bloody minimal discharge
 Pelvic Examination
INTERNAL AND BIMANUAL EXAMINATION

Introitus: admits 2 fingers with ease

Cervix: closed cervix
Uterus: Enlarged to 18-20 weeks size
Nonmovable, nontender
 SALIENT FEATURES
SUBJECTIVE OBJECTIVE
51 years old Vital Signs
G2P1 T= 36.7 C
Vaginal Bleeding PR = 107 bpm (Tachycardic)
Intermittent crampy hypogastric pain (5/10) RR = 21 cpm
BP = 110/80 mmHg

PHYSICAL EXAMINATION
pale conjunctiva, pallor

SPECULUM EXAM
pinkish, smooth, midline, scanty, bloody minimal
discharge

INTERNAL AND BIMANUAL EXAMINATION

Introitus: admits 2 fingers with ease

Cervix: closed cervix
Uterus: Enlarged to 18-20 weeks size
Nonmovable, nontender
 INITIAL LABORATORIES AT THE ER

CBC CLINICAL CHEM URINALYSIS

Hgb 68 (L) SGPT 14.6 (N) pH 5.0

Hct 0.21 (L) Creatinine 40.01 (N) S. gravity 1.008
RBC 2.36 (L)
Na 137 (N) Sugar Neg
WBC 10.82 (N)
Platelet 286 (N) K 3.7 (N) Albumin Neg
MCV 88.10 (N) Ca 2.08 (N) RBC 2
MCH 28.8 (N)
MCHC 32.7 (N)
Normocytic
Normochromic Anemia
Differentials
 Vaginal Bleeding
PALM: STRUCTURAL CAUSES
Malignancy and
Polyp Adenomyosis Leiomyoma Hyperplasia

COEIN: NON- STRUCTURAL CAUSES

Ovulatory Not Yet
Coagulopathy Endometrial Iatrogenic
dysfunction Classified
chronic use of warfarin, Common just after Ovulatory cycle with no No hx of exogenous Ateriovenous
heparin, LMW heparin menarche and before structural or systematic hormone use malformations
menopause abnormalities Possible Associations with some
Normal bleeding causes systematic diseases
paramters and PT count No hx of Endometritis
endocrinopathiesq
 PALM DIFFERENTIALS
POLYP?
POLYP
ADENOMYOSIS Found in all age groups, but mostly in
older women
LEIOMYOMA
May present as heavy menstrual,
MALIGNANCY OR HYPERPLASIA intermenstrual, or postmenstrual
bleeding
may be associated with dysmenorrhea
Polyps in the endometrium diagnosed by
ultrasound and hysteroscopy
 PALM
DIFFERENTIALS
POLYP Adenomyosis?
ADENOMYOSIS Classic symptoms:
LEIOMYOMA - Dysmenorrhea/ Hypogastric pain
- Heavy menstrual bleeding n
MALIGNANCY OR HYPERPLASIA
Diffusedly enlarged uterus; unusual to be
larger than > 14 weeks size without
associated myoma
Uterus is globular and tender immediately
before menstruation
 PALM DIFFERENTIALS
POLYP Leiomyoma
ADENOMYOSIS Risk factors:
Age
LEIOMYOMA Early menarche
MALIGNANCY OR HYPERPLASIA Symptoms include:
- Pelvic pain
- Pressure symptoms
- Abnormal uterine bleeding
- Infertility
 PALM DIFFERENTIALS
Malignancy or
POLYP Hyperplasia?
ADENOMYOSIS
LEIOMYOMA
MALIGNANCY OR HYPERPLASIA

requires analysis of tissue sample

 ENLARGED ANTEVERTED UTERUS WITH DIFFUSE
ADENOMYOSIS MORE PROMINENT ANTERIORLY AND
MYOMA UTERI ANTERIORLY

TVS
ADENOMATOUS POLYP WITH ATROPHIC ENDOMETRIUM

ENDOMETRIAL BIOPSY
 INITIAL
IMPRESSION
ABNORMAL UTERINE BLEEDING SECONDARY TO
ADENOMYOSIS; MYOMA UTERI; SEVERE ANEMIA
SECONDARY
Admitting order
 DAT
PNSS 1 L at KVO
Labs:
CBC, UA, BT, HbsAg
S. Crea, SGPT, Na, K, Ca
APTT, PT
ECG 12 Leads
CXR-PA
For Blood Transfusion
To secure 4 units of PRBC/WB of patients BT
Furosemide 20 mg IVTT post BT
Meds:
FeSO4 tab BID
Tranexamic acid 500 mg/tab TID
Ascorbic acid 500 mg/tab
DISCUSSION
 ADENOMYOSIS
endometriosis interna
Presence of endometrial tissue within the uterine wall (myometrium)
Derived from aberrant glands of the basalis layer of the endometrium

Pathogenesis is unknown it is theorized to be associated with disruption of

the barrier between the endometrium and the myometrium

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 ADENOMYOSIS : RISK FACTORS

Increased Parity
Prior Uterine Surgeries
Uterine Trauma

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 ADENOMYOSIS: CLINICAL DIAGNOSIS
Asymptomatic (Over 50%)

Symptomatic : 35-50 years old

-Secondary Dysmenorrhea
-Menorrhagia
-Dyspareunia
- PELVIC EXAMINATION: DIFFUSELY ENLARGED UTERUS
(2-3 times the normal size)
SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 ADENOMYOSIS: DEFINITIVE DIAGNOSIS
HISTOPATHOLOGIC FINDINGS :
ENDOMETRIAL GLANDS AND STROMA MORE THAN ONE LOW-POWER FIELD (2.5MM)
FROM THE BASALIS LAYER OF THE ENDOMETRIUM

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 ADENOMYOSIS: MANAGEMENT
HYSTERECTOMY : Definitive Treatment if it is appropriate for the
womans age, parity, and plans for future reproduction.

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 LEIOMYOMA
Most frequent pelvic tumor and most common tumor in
women
5th decade

Pathogenesis: somatic mutation and clonal expansion

Estrogen,Progesterone, and other Local Growth
Factors
 LEIOMYOMA : RISK FACTORS
- Genetic
- Increasing Age
- Early Menarche
- Low Parity
- Tamoxifen Use

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 LEIOMYOMA: TYPES

SUBMUCOUS MYOMA
- 5-10%
- Abnormal Vaginal Bleeding
- Distortion of Uterine Cavity
- May become pedunculated : PROLAPSED
MYOMA
 LEIOMYOMA: TYPES

SUBSREROUS MYOMA
- Knobby contour uterus
- May become pedunculated
- May outgrow uterine blood supply and
obtain secondary blood supply from other
organs : PARASITIC MYOMA
 LEIOMYOMA: CLINICAL DIAGNOSIS
Symptomatic :
- abnormal Uterine Bleeding : Menorrhagaia
- Pelvic Pressure/Pain : Dysmenorrhea, Dysuria, Bowel Changes, Urinary
Frequency/Symptoms

PELVIC EXAM: Large, firm, irregular uterus may be felt

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 LEIOMYOMA: DEFINITIVE DIAGNOSIS
HISTOPATHOLOGIC FINDINGS:
GROSSLY: Appear as whorled pattern of smooth muscle bundles, sharp, discrete, round,
firm, gray white
MICROSCOPICALLY: whorled bundles of smooth muscle cells that resemble the
uninvolved myometrium

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 LEIOMYOMA: MANAGEMENT
MYOMECTOMY AND HYTERECTOMY: Definitive Treatment if it is
appropriate for the womans age, parity, and plans for future
reproduction.

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 LEIOMYOMA: MANAGEMENT
INDICATIONS FOR MYOMECTOMY:
- PERSISTENT ABNORMAL BLEEDING
- PERSISTENT PAIN OR PRESSURE
- ENLARGEMENT OF AN ASYMPTOMATIC MYOMA (>8CM) IN A
WOMAN WHO HAS NOT COMPLETED CHOLD BEARING AGE

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
 LEIOMYOMA: MANAGEMENT
CONTRAINDICATIONS FOR MYOMECTOMY:
- PREGNANCY
- ADVANCED ADNEXAL DISEASE
- MALIGNANCY

SOURCE: Comprehensive
Gynecology 6th edition by
lentz et al
THANK YOU