Core Clinical Cases In Obstetrics and Gynaecology A problem-solving approach 2nd edition Janesh K. Gupta MSc MD FRCOG Clinical Senior Lecturer/ Honorary Consultant in Obstetrics and Gynaecology, University of Birmingham, Birmingham Women’s Hospital, Birmingham, UK Gary Mires MBChB MD FRCOG ILTM Clinical Reader and Honorary Consultant Obstetrician, Division of Maternal and Child Health Sciences, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK Khalid S. Khan MRCOG MSc MMEd Consultant Obstetrician and Gynaecologist and Clinical Sub-Dean, Birmingham Women’s Hospital, University of Birmingham, Birmingham, UK Core Clinical Cases series edited by Janesh K. Gupta MSc MD FRCOG Clinical Senior Lecturer/ Honorary Consultant in Obstetrics and Gynaecology, University of Birmingham, Birmingham Women’s Hospital, Birmingham, UK Hodder Arnold A MEMBER OF THE HODDER HEADLINE GROUP By Ashraf Nabhan at 1:33 am, Oct 16, 2011 First published in Great Britain in 2005 by Hodder Education, a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH http://www.hoddereducation.co.uk Distributed in the United States of America by Oxford University Press Inc., 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press © 2006 Janesh K. Gupta, Gary Mires and Khalid S. Khan 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: 90 Tottenham Court Road, London W1T 4LP. 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-10: 0 340 81672 4 ISBN-13: 978 0 340 81672 1 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Georgina Bentliff Project Editor: Heather Smith Production Controller: Jane Lawrence Cover Design: Georgina Hewitt Typeset in 9 on 12 pt Frutiger Light Condensed by Phoenix Photosetting, Chatham, Kent Printed and bound in Malta. What do you think about this book? Or any other Hodder Arnold title? Please visit our website at www.hoddereducation.co.uk Contents � Series preface vi � Preface to the first edition viii � Abbreviations used for investigations x OBSTETRICS Chapter 1 Early pregnancy problems 1 Chapter 2 Pregnancy dating and fetal growth 15 Chapter 3 Late pregnancy problems 33 Chapter 4 Labour 45 Chapter 5 Medical disorders of pregnancy 61 Chapter 6 Puerperium 73 GYNAECOLOGY Chapter 7 Abnormal uterine bleeding 83 Chapter 8 Amenorrhoea and menopause 95 Chapter 9 Incontinence and prolapse 109 Chapter 10 Neoplasia 123 Chapter 11 Discharge and pain 135 Chapter 12 Infertility 149 Chapter 13 Fertility control 161 Index 175 Series preface ‘A History Lesson’ Between about 1916 and 1927 a puzzling illness appeared and swept around the world. Dr von Economo first described encephalitis lethargica (EL), which simply meant ‘inflammation of the brain that makes you tired’. Younger people, especially women, seemed to be more vulnerable but the disease affected people of all ages. People with EL developed a ‘sleep disorder’, fever, headache and weakness, which led to a prolonged state of unconsciousness. The EL epidemic occurred during the same time period as the 1918 influenza pandemic, and the two outbreaks have been linked ever since in the medical literature. Some confused it with the epidemic of Spanish flu at that time whereas others blamed weapons used in World War I. Encephalitis lethargica was dramatized by the film Awakenings (book written by Oliver Sacks who is an eminent neurologist from New York), starring Robin Williams and Robert De Niro. Professor Sacks treated his patients with L-dopa, which temporarily awoke his patients giving rise to the belief that the condition was related to Parkinson’s disease. Since the 1916–27 epidemic, only sporadic cases have been described. Pathological studies have revealed encephalitis of the midbrain and basal ganglia, with lymphocyte (predominantly plasma cell) infiltration. Recent examination of archived EL brain material has failed to demonstrate influenza RNA, adding to the evidence that EL was not invasive influenza encephalitis. Further investigations found no evidence of viral encephalitis or other recognized causes of rapid-onset parkinsonism. Magnetic resonance imaging of the brain was normal in 60 per cent but showed inflammatory changes localized to the deep grey matter in 40 per cent of patients. As late as the end of twentieth century, it seemed that the possible answers lied in the clinical presentation of the patients in the 1916–27 epidemic. It had been noted by the clinicians, at that time, that the central nervous system (CNS) disorder had presented with pharyngitis. This led to the possibility of a post-infectious autoimmune CNS disorder similar to Sydenham’s chorea, in which group A b-haemolytic streptococcal antibodies cross-react with the basal ganglia and result in abnormal behaviour and involuntary movements. Anti- streptolysin-O titres have subsequently been found to be elevated in most of these patients. It seemed possible that autoimmune antibodies may cause remitting parkinsonian signs subsequent to streptococcal tonsillitis as part of the spectrum of post-streptococcal CNS disease. Could it be that the 80-year mystery of EL has been solved relying on the patient’s clinical history of presentation, rather than focusing on expensive investigations? More research in this area will give us the definitive answer. This scenario is not dissimilar to the controversy about the idea that streptococcal infections were aetiologically related to rheumatic fever. With this example of a truly fascinating history lesson, we hope that you will endeavour to use the patient’s clinical history as your most powerful diagnostic tool to make the correct diagnosis. If you do you are likely to be right between 80 and 90 per cent of the time.This is the basis of all the Core Clinical Cases series, which make you systematically explore clinical problems through the clinical history of presentation, followed by examination and then performing appropriate investigations. Never break those rules! Janesh Gupta 2006 Series preface vii Preface to first edition Why core clinical cases? In undergraduate medical education there is a trend towards the development of ‘core’ curricula.The aim is to facilitate the teaching of essential and relevant knowledge, skills and attitudes.This is in sharp contrast to traditional curricula, where there was an emphasis on detailed factual information, often without any practical clinical relevance. Currently, students’ learning is being more commonly examined using objective structured clinical examinations which assess the practical use of knowledge, rather than the regurgitation of small-print information that was commonly emphasised in traditional examination methods.This book has defined the ‘core’ material for obstetrics and gynaecology by considering the common core clinical problems which may be encountered in primary and secondary care, and it provides a learning strategy to master this ‘core’ material for examinations. Why a problem-solving approach? In practice, patients present with clinical problems, which are explored through history, examination and investigation progressively leading from a differential to a definitive diagnosis. Unfortunately, standard textbooks tend to present the subject matter according to a pathophysiological classification which does not help to prepare students to confront clinical scenarios.We have therefore based this book on a problem-solving approach.This inculcates the capacity for critical thinking and helps students to analyse the basis of clinical problems. The deep understanding of learning issues acquired in this way means that knowledge can be more easily retrieved both to solve real patients’ problems in the future and to answer confidently clinical questions encountered in examinations. How will this book inspire problem-solving traits? The short case scenarios presented in this book are based on common core clinical cases which students are likely to encounter in an undergraduate obstetrics and gynaecology module.We have grouped these cases according to areas of patients’ complaints.There are seven groups in the gynaecology category and six groups in obstetrics. Each group includes five or six cases, which begin with a statement of the patient’s complaint followed by a short description of the patient’s problem. For each case, using a question and short answer format, the student is taken through a problem-solving exercise.There are two types of problem-solving cases in this book. One type deals with the development of a diagnostic and therapeutic strategy, and the other deals with the development of a counselling strategy.The sequence of the cases and questions in each patient’s problem group is a logical one, taking the student from basics to the advanced aspects of clinical care. ‘Core’ information about the subject matter relevant to the patient’s problem is also summarized, as this information is helpful for answering the questions.The format of the book enables the cases to be used for learning as well as for self- assessment. In the cases that deal with diagnostic and therapeutic strategies, the student is questioned about the interpretation of all the relevant clinical features presented, in order to compile an array of likely differential diagnoses.They are then asked to identify specific pieces of information in the history and to select an appropriate clinical examination which will narrow down the differential list to the most likely diagnosis.This emphasis is important because, in clinical practice, history and examination alone result in a correct diagnosis in 80–90 per cent of patients. Following this, students are asked to suggest the investigations which would be required to confirm or refute the diagnosis. Once the diagnosis has been reached, students will develop a treatment plan. In general, this plan should first consider conservative non-invasive options (e.g. doing nothing), followed by medical and finally surgical options. The therapeutic strategy will also have to be conveyed to the patient in a manner that he or she can understand.Therefore in each group, patient problems that will challenge students to develop a counselling strategy have been included.These counselling cases will help students to communicate confidently with patients (one counselling case has been included in the last chapter which gives an idea of the marking system that may be used in an examination situation).This generic learning strategy is followed throughout the book with the aim of reinforcing the skills required to master the problem-solving approach. J.K. Gupta G. Mires K.S. Khan Preface to first edition ix Abbreviations used for investigations ✓ investigation required ± optional investigation ✗ investigation not required bhCG b human chorionic gonadotrophin AFI amniotic fluid index AFP a-fetoprotein ARM artificial rupture of the membranes BPD biparietal diameter CHD coronary heart disease COC combined oral contraceptive pill CT computed tomography CTG cardiotocograph D&C dilatation and curettage DIC disseminated intravascular coagulation DUB dysfunctional uterine bleeding DVT deep vein thrombosis EDD estimated date of delivery FAC fetal abdominal circumference FBC full blood count FHR fetal heart rate FSH follicle-stimulating hormone GnRH gonadotrophin-releasing hormone GSI genuine stress incontinence HELLP haemolysis, elevated liver enzymes and low platelets HPV human papilloma virus HRT hormone replacement therapy HSV herpes simplex virus HVS high vaginal swab ICSI intracytoplasmic sperm injection Ig immunoglobulin IUCD intrauterine contraceptive device IUGR intrauterine growth restriction IVF in vitro fertilization IVF-ET in vitro fertilization and embryo transfer LFD large for dates LFT liver function test LH luteinizing hormone LLETZ large loop excision of the transformation zone LMP last menstrual period MCV mean cell volume MCH mean cell haemoglobin MRI magnetic resonance imaging MSU midstream specimen of urine NSAID non-steroidal anti-inflammatory drug PCOS polycystic ovarian syndrome PID pelvic inflammatory disease Abbreviations used for investigations xi PMB postmenopausal bleeding POP progesterone-only pill RDS respiratory distress syndrome SGA small for gestational age SSRI selective serotonin reuptake inhibitor STI sexually transmitted infection TENS transcutaneous electrical nerve stimulation TFT thyroid function test TSH thyroid-stimulating hormone TTN tachypnoea of the newborn U&Es urea and electrolytes USS ultrasound scan UTI urinary tract infection WCC white cell count xii Abbreviations used for investigations Early Pregnancy Problems Questions Cases Key concepts Answers 1 Questions for each of the case scenarios given Clinical cases CASE 1.1 – My period is 2 weeks late and I am bleeding. A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea. She has not been using any contraception. She normally has a regular menstrual cycle every 28 days.A pregnancy home test is positive. She has noticed slight vaginal spotting. CASE 1.2 – I am 6 weeks pregnant and have pain and bleeding. A 34-year-old woman presents with a history of 6 weeks of amenorrhoea, abdominal pain and slight vaginal bleeding. She stopped the oral contraceptive pill 2 years ago in order to conceive, and she recently booked an appointment to see her doctor because she was concerned that she was infertile. She has previously had an appendectomy and pelvic inflammatory disease (PID). Recently she has been feeling dizzy.A home pregnancy test is positive. CASE 1.3 – I am pregnant and cannot keep anything down. A 26-year-old primigravida presents at 8 weeks’ gestation with a history of nausea and vomiting for the last 2 weeks. However, over the past 48 h she indicates that she has been unable to keep any food or drink down. Q1: What is the likely differential diagnosis? Q2: What issues in the given history support the diagnosis? Q3: What additional features in the history would you seek to support a particular diagnosis? Q4: What clinical examination would you perform and why? Q5: What investigations would be most helpful and why? Q6: What treatment options are appropriate? ? 2 Obstetrics OSCE counselling cases OSCE COUNSELLING CASE 1.1 – I am upset that my first pregnancy has ended in a miscarriage. A 23-year-old woman has had an evacuation of the uterus following an incomplete miscarriage at 10 weeks’ gestation in her first pregnancy. She is ready for discharge home and very upset. Q1: What counselling would you give her about miscarriage and about postoperative recovery before discharge? OSCE COUNSELLING CASE 1.2 – This is my third miscarriage. What can be done about it? A patient has just undergone an evacuation of the uterus for her third consecutive spontaneous miscarriage. She has had no pregnancies beyond 10 weeks’ gestation. Q1: What investigations should be undertaken? Q2: In the absence of any identifiable cause, what are her chances of achieving an ongoing pregnancy on the next occasion? OSCE counselling cases 3 Key concepts In order to work through the core clinical cases in this chapter, you will need to understand the following key concepts. Bleeding in early pregnancy � Bleeding in early pregnancy is very common � Twenty per cent of pregnancies undergo spontaneous miscarriage. � Ectopic pregnancy should be considered in the differential diagnosis in all women of reproductive age presenting with abdominal pain and vaginal bleeding. 4 Obstetrics Answers CASE 1.1 – My period is 2 weeks late and I am bleeding. Q1: What is the likely differential diagnosis? A1 ● Miscarriage � threatened miscarriage; � inevitable miscarriage; � incomplete miscarriage; � complete miscarriage; � missed miscarriage. ● Ectopic pregnancy (see Case 1.2). ● Molar pregnancy. Q2: What issues in the given history support the diagnosis? A2 Six weeks of amenorrhoea and a positive pregnancy test, after regular menstrual cycles, indicate an early pregnancy.The small amount of bleeding is a sign that the patient is threatening to have a miscarriage. However, a firm diagnosis can be established only after further investigations. Q3: What additional features in the history would you seek to support a particular diagnosis? A3 The degree of bleeding, associated pain and passage of products of conception would indicate the type of miscarriage (Table 1.1). Answers 5 A