OG integrated teaching

8/7/2019 OG integrated teaching

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Case no. 2

Ashwin. R


2/22

A 30 yr old lady presented to the gynaec OPD

with her husband with complaints of not

conceiving even after 3 years of marriage.

She also complaints of dysmenorrhea and

bilateral pelvic pain which was more on the

left side.


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30 yrs not conceiving

bilateral pelvic pain (L)Dysmenorrhea


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She attained her menarche at the age of 13. she

was having regular menses without dysmenorrhea

till 25 yrs of age. After that she started having

dysmenorrhea which begins before the onset of

menses, continuing throughout the cycle and the

severity is more nowadays


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bilateral pelvic pain (L)Dysmenorrhea X 5y

onset / progress / relation to the cycle TYPE ?

VARIETY ?


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Dysmenorrhea - types

PRIMARY SECONDARY

ONSET Within 2 yrs of menarche 20-30 yrs,

pre/postmenstrual

SYMPTOMS NVD, headache , fatigue Dyspareunia,

infertility, menstural

disorders

PAIN Cramping hypogastrium,

inner thigs, back

Dull aching - variable


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Dysmenorrhea - varieties

Spasmodic : cramping pains, more in the 1st

and 2nd day of menstruation

Congestive : increasing pelvic discomfort and

pain few days before the menses

Membranous : painful uterine cramps at

menstruation


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bilateral pelvic pain (L)Dysmenorrhea X 5y

Secondary

congestive


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Endometriosis

Chronic PID

ovarian tumour (B/M) Uterine myomas -

can be ruled out with a transvaginal USG

Differential diagnoses


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Husbands seminogram shows normal

findings.

TVS (colour doppler) of the lady shows a left

adnexal mass, 5cm in size, with homogenous

internal echoes and increased vascularity at

the ovarian hilus


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TV USG / Colour doppler


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USG again


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Endometriosis of the ovary

Chronic PID with TO mass

ovarian tumour (B/M) Uterine myomas

Differential diagnoses


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PID ? Why not ?

TV USG findings

Features of PID Low grade fever with acute episodes (A/C)

lassitude

Foul smelling discharge per vagina

Colour doppler findings in this patient


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low resistance flow, Increased vascularity at

the hilus

Ovarian carcinoma ??

Age Associated features of Ovarian CA ?


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ENDOMETRIOMA LEFT OVARY

Chocolate cyst


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Endometriosis - sites

Most common site ,ovaries (~60%)


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The scenario

A 30 yr old lady who has come with pain and

has to conceive

A moderately large ovarian chocolate cyst (5cm) in the left side

No other probable sites of involvement


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Management

To cover

Pelvic pain

Ovarian endometrioma infertility


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For this patient ,

Discuss regarding the different options & cost

NSAIDs for immediate pain relief

Start on GnRH analogue

Goserelin acetate (Zoladex) 3.6 mg depot X 3mths

Evaluate for infertility meanwhile

Laparoscopic cyst excision (preferably) after 3months

Post operative hormone therapy for residual tissue


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Lap cyst excision


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