Gynecologic Case Studies: Seeing the Full Picture
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1 Disclosures Gynecologic Case Studies: Seeing the Full Picture No relevant financial relationships No discussion of products which are investigational or not labeled for the use under discussion North Carolina Ultrasound Society 33 rd Annual Symposium Saturday, April 12, 2014 Alice Chuang, MD, FACOG University of North Carolina Department of Obstetrics and Gynecology Department of Objectives Describe management plans for general gynecologic problems Understand how those plans are shaped by ultrasound findings Provide more clinically useful gynecologic ultrasound examinations and interpretations Attention paid to lecturer (%) Settling into lecture, previewing lecture slides Has renewed sense of interest in topic at hand Time (min) Is finding lecture material somewhat mundane, starts wondering what is for lunch Adult Learner Listens intently, hoping to catch key summary points Case 1 Definitions A 45 year old female comes to the clinic with a 7 month history of heavy menses. She reports that she has heavier bleeding with each cycle as well as spotting in between. She finds this all very inconvenient. Menorrhagia: heavy regular menstrual bleeding Metrorrhagia: irregular bleeding Menometrorrhagia: heavy and irregular bleeding Changes in nomenclature The term abnormal uterine bleeding should be replaced by coagulopathy, endometrial disorder, and ovulatory disturbance 1
2 FIGO terminology PALM-COEIN Classification Created by International Federation of Gynecology and Obstetrics (FIGO) A classification schema for causes of irregular uterine bleeding in non-gravid women of reproductive age 9 categories PALM: polyp, adenomyosis, leiomyoma, malignancy/hyperplasia COEI: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic N: not yet classified Intramural Submucosal Subserosal Exophytic Pedunculated Parisitic 11/fibroid-uterus jpg Possible interventions Uterine artery occlusion Via laparoscopy or a vaginally-placed clamp Uterine artery embolization (UAE) Done by interventional radiology MR-guided Focused Ultrasound (MrgFUS) Hysteroscopy with endometrial ablation Laparoscopic thermal coagulation or cryoablation Myomectomy Hysterectomy (vaginal, abdominal, laparoscopic, laparoscopic-assisted, robotic) 2
3 Case 2 A 24 year old presents to the Emergency Department with a 2 day history of abdominal pain. She reports that it comes and goes and rates it a 8/
4 Abdominal pain: What could it be? Cholelithiasis Biliary colic Acute cholecystitis Acute cholangiits Pancreatitis Biliary dyskinesia Dyspepsia Splenic abscess Splenic infarct Irritable bowel Gastric cancer Pancreatic cancer Diabetic gastroparesis Ischemic heart disease Myocardial infarction Pneumonia Diverticulitis Renal calculi Bladder outlet obstruction Mesenteric ischemia Ruptured abdominal aortic aneurysm Normal labor Radiculitis Psoas abscess Hepatitis Cirrhosis Appendicitis Abdominal hernia Intestinal obstruction Abdominal wall spasm Incarcerated hernia Abdominal wall Severe constipation hematoma Pelvic inflammatory disease Abdominal migraine Ovarian cyst Mesenteric adenitis Paratubal cyst Perforated ulcer Mittelschmerz Eosinophilic Adnexal torsion gastroenteritis testicular torsion Epiploic appendagitis Ruptured ovarian cyst Ruptured ectopic pregnancy Fitz-Hugh-Curtis Unruptured ectopic pregnancy Degenerating fibroid Familial Mediterranean fever Endomyometritis Ovarian neoplasm Hereditary angioedema Tubal neoplasm Diabatic ketoacidosis Dysmenorrhea Endometriosis Acute intermittent Rupture of endometrioma porphyria Typhoid fever Lactose intolerance Normal pregnancy Gastroenteritis Bowel wall hematoma Helminthic infections Vaso-occlusive crisis Painful rib Ileus Psychosomatization Wandering spleen Adhesive disease Crohn s disease Ulcerative colitis Bacllary dysentery Food poisoning Cholera Carcinoid Irritable bowel Functional dyspepsia Celiac artery compression Diverticulosis Excessive bowel gas Mesenteric adenitis Meckels diverticulum Cystitis Mallory-Weiss tear Esophagitis Hiatal hernia Pernicious anemia Subphrenic abscess Splenic infarction Hepatic abscess Anxiety Adrenal crisis
5 Observation Pain control Interventions Laparoscopy for diagnosis Ovarian cystectomy Precautions for torsion Bendometrioma2.JPG Case 3 Normal endometrium A 55 year old, who has been postmenopausal for four years, reports she has had 7 days of spotting. raphics.rsna. org/content/ 21/6/1409/F 16.small.gif ENDOMETRIAL PIPELLE ces/glowm/graphics/figures/v4 /0120/004f.jpg om/images/womens/feature/f eature_econo_samp.jpg 5
6 Case 4 A 33 year old comes to see her gynecologist for a string check 6 weeks after placing her IUD (a Mirena or levonorgestrel IUD). She reports that she has had some mild cramping, but nothing out of the ordinary. However, she has changed her mind about the IUD and would like it removed. Case 4 (cont.) Thread Retrievers On physicial exam, no IUD strings are seen. Attempts to locate the string are unsuccessful. Attempts to remove the IUD are unsuccessful. IUD Hooks Grasping Devices 6
7 7
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