,100 CASES
in Obstetrics and Gynaecology
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100 CASES
in Obstetrics and Gynaecology
Cecilia Bottomley MB BChir MRCOG
Clinical Lecturer in Obstetrics and Gynaecology, St George’s, University of London, UK
Janice Rymer MD FRCOG FRANZCOG FHEA
Professor of Obstetrics and Gynaecology, King’s College London School of Medicine at Guy’s, King’s
and St Thomas’ Hospitals, London, UK
100 Cases Series Editor:
P John Rees MD FRCP
Dean of Medical Undergraduate Education, King’s College London School of Medicine at
Guy’s, King’s and St Thomas’ Hospitals, London, UK
,First published in Great Britain in 2008 by
Hodder Arnold, an imprint of Hodder Education, part of Hachette Livre UK 338 Euston
Road, London NW1 3BH
© 2008 Cecilia Bottomley
All rights reserved. Apart from any use permitted under UK copyright law, this publication may only be
reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the
publishers or in the case of reprographic production in accordance with the terms of licences issued by the
Copyright Licensing Agency. In the United Kingdom such licences are issued by the Copyright licensing Agency:
Saffron House, 6-10 Kirby Street, London EC1N 8TS.
Whilst the advice and information in this book are believed to be true and accurate at the date of going to
press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or
omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer)
every effort has been made to check drug dosages; however it is still possible that errors have been missed.
Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these
reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering
any of the drugs recommended in this book.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress ISBN 978 0
340 94744 9
1 2 3 4 5 6 7 8 9 10
Commissioning Editor: Sara Purdy Project Editor: Jane Tod
Production Controller: Andre Sim Cover Design: Laura
DeGrasse
Indexer: Indexing Specialists (UK) Ltd
,CONTENTS
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PREFACE
Learning in medicine has gradually moved away from an apprentice system to a more structured course format.
Advances have been made with the use of simulated cases, problem-based learning and electronic learning
resources; however, this has led to a separation of the learning environment from the clinical art of real medicine.
This book aims to redress the balance with entirely clinical cases, highlighting the history and examination features
with salient investigations. This allows the reader to place themselves in the position of the practising doctor
encountering these scenarios in the everyday clinical setting.
Obstetrics and gynaecology involves the same clinical reasoning as other specialties covered in this series, but
several points should be highlighted. First most patients seen in obstetrics and gynaecology are generally fit and
healthy. As such they will withstand cardiovascular insults such as haemorrhage very effectively by increasing
cardiac output. Signs of tachycardia and hypovolaemia may be late and signify severe compromise. Second, there
are many physiological changes in pregnancy and normal ranges therefore alter. Where indicated, normal values
for pregnant and non-pregnant women have been included. Finally, many abnormalities in obstetrics and
gynaecology are picked up during ‘routine’ care. This book therefore differs from those of Clinical Medicine and
Surgery in that women do not always ‘present’ with a problem, but one may be detected through, for example,
routine antenatal care or during a cervical smear investigation.
The cases are grouped into broad categories with random ordering of cases within each category to mimic the way
cases present in clinical practice.
We have written this book with both clinicians and medical students in mind, with cases varying in complexity, to
reinforce common or important subject areas. We hope they will stimulate and challenge as well as build confidence
for those working in or learning obstetrics and gynaecology.
Cecilia Bottomley Janice Rymer
January 2008
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ACKNOWLEDGEMENTS
The authors would like to thank the following people for their help with illustrations and useful suggestions for
cases: Dr Anna Belli, Mr Tom Bourne, Miss Jan Grace, Mr Kevin Hayes, Dr Emma Kirk, Miss Gini Lowe, Dr
Jasper Verguts and Dr Miles Walkden.
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ABBREVIATIONS
AFP alpha-fetoprotein
APH antepartum haemorrhage
APTT activated partial thromboplastin time ARM artificial
rupture of membranes
BMI body mass index
BV bacterial vaginosis
CIN cervical intraepithelial neoplasia COCP combined oral
contraceptive pill CT computerized tomography
CTG cardiotocograph
CTPA computerized tomography pulmonary angiogram CVS chorionic
villous sampling
DCDA dichorionic diamniotic
DIC disseminated intravascular coagulopathy DUB
dysfunctional uterine bleeding
,EAS external anal sphincter ECG
electrocardiogram
EIA enzyme immunoassay
ERPC evacuation of retained products of conception FBS fetal
blood sampling
FSH follicle-stimulating hormone
FTA-abs treponemal antibody-absorbed (test) GBS group
B streptococcus
GDM gestational diabetes mellitus GP general
practitioner
Hb haemoglobin
HCG human chorionic gonadotrophin
HELLP haemolysis, elevated liver enzymes and low platelets HIV human
immunodeficiency virus
HRT hormone replacement therapy IAS internal
anal sphincter
Ig immunoglobulin
INR international normalized ratio IUCD intrauterine
contraceptive device IUS intrauterine system
IVF in vitro fertilization
LLETZ large-loop excision of the transformation zone LH
luteinizing hormone
LMP last menstrual period date MCH mean cell
haemoglobin MoM multiples of the median
MRI magnetic resonance imaging
Abbreviations
NT nuchal translucency
OAB overactive bladder syndrome OC obstetric
cholestasis
PCA patient-controlled analgesia PCOS
polycystic ovarian syndrome PE
pulmonary embolism
PIH pregnancy-induced hypertension PMB
postmenopausal bleeding
PMS premenstrual syndrome POP progesterone
only pill PPH postpartum haemorrhage
PUL pregnancy of unknown location RDS respiratory
distress syndrome SLE systemic lupus erythematosus SPD
symphysiopelvic dysfunction STI sexually
transmitted infection
TCRF transcervical resection of a fibroid TEDS
thromboembolic stockings
TIBC total iron-binding capacity TPN total parenteral
nutrition TSH thyroid-stimulating hormone T3 tri-
iodothyronine
T4 thyroxine
UTI urinary tract infection
VBAC vaginal birth after Caesarean
VDRL venereal disease research laboratory (test) VTE venous
thromboembolism
WHO World Health Organization
, GENERAL GYNAECOLOGY
History
A 48-year-old woman presents with intermenstrual bleeding for 2 months. Episodes of bleeding occur any time in
the cycle. This is usually fresh red blood and much lighter than a normal period. It can last for 1–6 days. There is
no associated pain. She has no hot flushes or night sweats. She is sexually active and has not noticed vaginal
dryness.
She has three children and has used the progesterone only pill for contraception for 5 years.
Her last smear test was 2 years ago and all smears have been normal. She takes no medi- cation and has no other
relevant medical history.
Examination
The abdomen is unremarkable. Speculum examination shows a slightly atrophic-looking vagina and cervix but
there are no apparent cervical lesions and there is no current bleeding.
On bimanual examination the uterus is non-tender and of normal size, axial and mobile. There are no adnexal
masses.
INVESTIGATIONS
Normal range
Haemoglobin 12.7 g/dL 11.7–15.7g/dL
White cell count 4.5 × 109/L 3.5–11 × 109/L
Platelets 401 × 109/L 150–440 × 109/L
Transvaginal ultrasound scan and hydrosonography is shown in Fig. 1.1.
Figure 1.1
Questions
• What is the diagnosis and differential diagnosis?
• How would you further investigate and manage this woman?
The diagnosis is of an endometrial polyp, as shown by the hydrosonography image (Fig. 1.1). These can occur in
women of any age although they are more common in older women and may be asymptomatic or cause irregular
bleeding or discharge. The aetiology is uncertain and the vast majority are benign. In this specific case all the
, differential diag- noses are effectively excluded by the history and examination.
Differential diagnosis for intermenstrual bleeding
!
• Cervical malignancy
• Cervical ectropion
• Endocervical polyp
• Atrophic vaginitis
• Pregnancy
• Irregular bleeding related to the contraceptive pill
Management
Any woman should be investigated if bleeding occurs between periods. In women over the age of 40 years, serious
pathology, in particular endometrial carcinoma, should be excluded.
The polyp needs to be removed for two reasons:
• to eliminate the cause of the bleeding
• to obtain a histological report to ensure that it is not malignant.
Management involves outpatient or day case hysteroscopy, and
resection of the polyp under direct vision using a diathermy loop or other resection technique (Fig. 1.2). This allows
certainty that the polyp had been completely excised and also allows full inspec- tion of the rest of the cavity to
check for any other lesions or suspicious areas. In some settings, where hysteroscopic facilities are not available,
a dilatation and curettage may be carried out with blind avulsion of the polyp with polyp forceps. This was the
standard management in the past but is not the gold standard now, for the reasons explained.
Figure 1.2 Hysteroscopic appearance of endometrial
polyp prior to resection. See Plate 1 for colour image.
KEY POINTS
, • Any woman over the age of 40 years should be investigated if bleeding occurs
between the periods, to exclude serious pathology, in particular endometrial carcinoma.
• Hysteroscopy and dilatation and curettage is rarely indicated for women under
the age of 40 years.
History
A 31-year-old woman has been trying to conceive for nearly 3 years without success. Her last period started 7
months ago and she has been having periods sporadically for about 5 years. She bleeds for 2–7 days and the periods
occur with an interval of 2–9 months. There is no dysmenorrhoea but occasionally the bleeding is heavy.
She was pregnant once before at the age of 19 years and had a termination of pregnancy. She had a laparoscopy
several years ago for pelvic pain, which showed a normal pelvis.
Cervical smears have always been normal and there is no history of sexually transmitted infection.
The woman was diagnosed with irritable bowel syndrome when she was 25, after thor- ough investigation for other
bowel conditions. She currently uses metoclopramide to increase gut motility, and antispasmodics.
Her partner is fit and well, and has two children by a previous relationship. Neither part- ner drinks alcohol or
smokes.
INVESTIGATIONS
Normal
Follicle-stimulating hormone 3.1 IU/L Day 2–5
1–11 IU/L
Luteinizing hormone 2.9 IU/L Day 2–5
0.5–14.5 IU/L
Day 21 progesterone 12 nmol/L
Prolactin 1274 mu/L 90–520 mu/L
Testosterone 1.4 nmol/L 0.8–3.1 nmol/L
Thyroid-stimulating hormone 4.1 mu/L 0.5–7 mu/L
Free thyroxine 17 pmol/L 11–23 pmol/L
Questions
• What is the diagnosis and its aetiology?
• How would you further investigate and manage this couple?
The infertility is secondary to anovulation as shown by the day 21 progesterone (>30 nmol/L suggests
ovulation has occurred). Normal testosterone and gonadotrophins and high prolactin suggest the likely case of
anovulation is hyperprolactinaemia. Hyperprolactinaemia may be physiological in breast-feeding, pregnancy and
stress. The commonest causes of pathological hyperprolactinaemia are tumours and idiopathic hypersecretion, but
it may also be due to drugs, hypothyroidism, ectopic prolactin secretion or chronic renal failure. In this case the
metoclopramide is the cause, as it is a dopamine antagonist (dopamine usually acts via the hypothalamus to cause
inhibition of prolactin secretion, and if this is interrupted, prolactin is excreted to excess). Galactorrhoea is not a
common symptom of hyperprolactinaemia, occurring in less than half of affected women.
, Drugs associated with hyperprolactinaemia (due to dopamine antagonist effects)
!
• Metoclopramide
• Phenothiazines (e.g. chlorpromazine, prochlorperazine, thioridazine)
• Reserpine
• Methyldopa
• Omeprazole, ranitidine, bendrofluazide (rare associations)
The metoclopramide should be stopped and the woman reviewed after 4–6 weeks to ensure that the periods have
restarted and that the prolactin level has returned to normal. If this does not occur, then further investigation is
needed to exclude other causes of hyperprolactinaemia such as a pituitary micro- or macro-adenoma. It would be
advisable to repeat the day 21 progesterone level to confirm ovulatory cycles. The woman should have her rubella
immunity checked and should be advised to take preconceptual folic acid until 12 weeks of pregnancy.
If the woman fails to conceive then a full fertility investigation should be planned with semen analysis and tubal
patency testing (hysterosalpingogram or laparoscopy and dye test).
KEY POINTS
• A full drug history should be elicited in women with amenorrhoea or infertility.
• Galactorrhoea occurs in less than half of women with hyperprolactinaemia.
• Day 21 progesterone over 30 nmol/L is suggestive of ovulation.
History
A 32-year-old woman complains that she has not had a period for 3 months. Four home pregnancy tests have all
been negative. She started her periods at the age of 15 years and until 30 years she had a normal 27-day cycle. She
had one daughter by normal delivery 2 years ago, following which she breast-fed for 6 months. After that she had
normal cycles again for several months and then her periods stopped abruptly. She was using the progesterone only
pill for contraception while she was breast-feeding and stopped 6 months ago as she is keen to have another child.
She reports symptoms of dryness during intercourse and has experienced sweating episodes at night as well as
episodes of feeling extremely hot at any time of day. There is no relevant gynaecological history. The only medical
history of note is that she has been hypothyroid for 10 years and takes thyroxine 100 μg per day. She does not take
any alcohol, smoke or use recreational drugs.
Examination
Examination findings are unremarkable
INVESTIGATIONS
