Clinical Essays in Obstetrics and Gynaecology for MRCOG Part II (And Other Postgraduate Exams) Mala Arora, Seema Sharma
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89Gynecology
90

PAPER 1

  1. A 20-year-old nulliparous woman complains of severe bloating sensation, difficulty in sleeping and breast tenderness. She appears irritable and reveals that her periods are due in about a week. Enumerate the management options available to her.
Note: A good way to answer such questions is to add a word on diagnosis and divide the management options into supportive, medical and surgical options.
Premenstrual syndrome (PMS) is the most likely diagnosis if the symptoms have been present for at least 4 out of the previous six months. It has been renamed as premenstrual dysphoric disorder (PMDD). Other disorders manifesting episodically should be excluded by psychiatric evaluation.
PMDD shows a strong placebo effect. She should be handled sympathetically, and the likely etiology explained for reassurance. General measures like exercise, relaxation techniques like meditation and yoga may be beneficial. She should be encouraged to eat a well balanced diet with low salt and fat content to reduce premenstrual bloating. Alcohol, chocolate, dairy products and caffeinated beverages may accentuate her irritability and their intake should be restricted.
Evening primrose oil has been found to be effective especially for relieving the breast symptoms, and is also devoid of side effects. Supplements of vitamin B6 (pyridoxine), vitamin E, and gamma linoleic acid have also proved to be of some value.
The management options available to her are mainly for symptomatic relief. Since the disorder is often associated with ovulatory cycles only, suppression of ovulation has been tried. Combined contraceptive pills may be effective in some. Danazol 100–200 mg daily is effective in treating breast symptoms but may cause unacceptable side effects like hirsutism. GnRH agonists like Triptorelin or Luprolide are of limited value as they are costly, may cause osteopenia and can only be used for short periods of 6 months.
Severe bloating and weight gain may require the use of diuretics like Spironolactone, which is an aldosterone antagonist or Frusemide for short periods each month. However, its overuse is to be avoided as it can lead to diuretic induced hypokalemia. NSAIDs may be added in the late luteal phase for any associated dysmenorrhea.
Insomnia can be treated with anxiolytics like alprazolam or sedatives. Selective serotonin reuptake inhibitors like Fluoxitene 20 mg are becoming 92the first line therapy for PMDD because they are effective, well tolerated and free of major side effects. In depressive mood disorders, tricyclic antidepressants have been used.
The use of surgery is not an option due to her young age.
Thus, the management options in PMDD are mainly symptomatic and have to be tailored to suit the patient's symptoms. Its management is important because the symptoms of PMDD can lead to socioeconomic loss, and secondly because of associated legal implications that arise in conjunction with personal accountability in cases of PMDD.93
  1. You have just delivered a baby with ambiguous looking genitalia. Baby is otherwise normal. What advice will you give the parents regarding the condition and further management?
A newborn with ambiguous genitalia requires immediate investigation, not only because of parental anxiety but also because one of its causes, salt losing congenital adrenal hyperplasia may be rapidly fatal in the first week of life if the electrolyte levels are not closely monitored and corrected.
The parents should be counseled that ambiguous genitalia may be the result of a chromosomal disorder or more commonly may occur in a chromosomally normal infant, due to endocrinal abnormalities.
History of drug intake during pregnancy of androgenic progesterones should be elicited. Child should be examined to identify palpable gonads. In the absence of palpable gonads, it is most likely that the child is female and the parents should be informed as such.
Karyotyping should be done by examining the buccal smear for Barr bodies, doing a skin biopsy or analyzing the neutrophils in cord blood. Sex chromosome abnormalities that may be encountered are True hermaphroditism, i.e. XO/XY (rare), Turner's syndrome mosaics, Klinefelter's syndrome, normal XX or XY constitution.
17α-hydroxyprogesterone levels should be measured in blood and are elevated in CAH. Normal testosterone levels may indicate testicular feminization syndrome due to end organ insensitivity.
Serum electrolytes should be checked urgently to rule out the possibility of salt losing type of CAH. In this case sodium and chloride may be low and potassium raised. The salt losing type has in addition low aldosterone levels and requires immediate replacement steroid therapy. Electrolyte imbalance should be promptly corrected. If the electrolytes are normal, parents should be reassured that the child is healthy but there is a developmental anomaly of the genitalia.
Pelvic ultrasound should be performed to discover the presence of a uterus and vagina. Associated renal tract abnormalities should be looked for which can be found in 20% of patients. Laparotomy and gonadal biopsy may be required to establish the diagnosis in hermaphrodites.
Multidisciplinary team should be involved in the neonates care. Prompt correction of electrolyte imbalance, and cortisol for adrenocorticotropic hormone suppression are areas of immediate concern. Surgical correction of the external genitalia should be undertaken once the disorder has been brought under control.94
Note: The first diagnosis to be confirmed or refuted for such an infant is CAH. It is the commonest cause of a masculinised female and is due to deficiency of 21-hydroxylase enzyme which converts 17α-hydroxyprogesterone to desoxycortisol and progesterone to desoxycorticosterone.95
  1. A 36-year-old barrister has conceived in an IVF cycle. She is currently 7 weeks pregnant and an ultrasound reveals a gestational sac in right fallopian tube. Debate the various management options available to her.
When IVF is performed for diseased tubes, even though the embryos are replaced in the uterine cavity, under ultrasound guidance, there is documented retrograde migration of the embryos that can result in an ectopic gestation. This fact has to be explained to the patient sympathetically. An ectopic gestation post IVF is emotionally a traumatic event and patient counseling is required prior to deciding the mode of treatment.
For an unruptured 7 weeks ectopic pregnancy both medical and surgical management options are available. Expectant management is not an option as the incidence of rupture and hemorrhage are high.
  • Medical management as preferred line of therapy if the criteria are fulfilled such as sac diameter not more than 2.5 cm, no cardiac activity in fetal pole, β hCG levels less than 1500 miu/ml, no signs of fluid in the pelvis by ultrasound. Adequate counseling is required to impress upon the patient the need for strict follow-up, and the possibility of surgical intervention if there are signs of hemorrhage or pain. The drug of choice is methotrexate which is administered in a dose of 50 mg/m2, with monitoring of β hCG levels and ultrasonography post-therapy to evaluate response. Strict vigilance for signs of rupture of the ectopic pregnancy.
  • Surgical management is preferably by the laparoscopic route, if the expertise exists. This allows excision of the ectopic gestational sac following linear salpingotomy or even total salpingectomy if the tube is diseased. The contralateral tube should be inspected and if diseased or shows the presence of hydrosalpinx, its corneal end should be coagulated or clipped to prevent the occurrence of an ectopic on the other side. Laparoscopy allows faster postoperative recovery and can be performed as a day case, hence is cost effective. This is the procedure of choice if the criteria for medical management are not fulfilled.
  • Laparotomy and linear salpingotomy or total salpingectomy is also an option, but requires longer postoperative recovery and hospital stay.
  • SAM (Surgically administered medical therapy) using KCL injection in the fetal heart or methotrexate in the gestational sac under ultrasound guidance using an ovum pick up needle is also an option. It has the advantage of being less invasive, but requires strict follow-up with beta hCG and may 96require surgical intervention in the rare event of hemorrhage or rupture. Besides laparoscopy gives us the chance of inspecting the contralateral tube as well.
She should be reassured that a future pregnancy is possible through IVF subsequently.97
  1. A 53-year-old postmenopausal school teacher has been suffering from urinary incontinence for the last 5 years. Discuss relevant investigations and treatment options.
Complete gynecological and medical, surgical history should be elicited, including a history of chronic cough, smoking, constipation or uterocervical descent. These, if present, will need simultaneous correction. Past history of any medical therapy for incontinence followed by general, systemic and gynecological examination to demonstrate stress urinary incontinence if present.
Bonney's 3 swab test will distinguish stress incontinence from vesico-vaginal fistula, and a Q tip placed at the bladder neck will tell us about bladder neck descent. Investigations in the form of urine routine and microscopic examination should be done to check the specific gravity of the urine which is low in diabetes insipidus or inappropriate ADH syndrome. Urine culture and sensitivity should be done to rule out urinary tract infection, which should be treated prior to any surgical intervention. Ultrasound of the lower abdomen will pick up any ureteric or vesical stones that can result in both urinary infection as well as urinary urgency. A post void volume check should be made on ultrasound scan which will tell us about overflow incontinence.
Urodynamic testing to know if detrusor instability is present, offer and blood sugar for diabetes. Maintenence of a fluid intake/void diary will tell us about the social incapacitation from incontinence and also if fluid restriction would help.
Treatment options would depend on the type of incontinence.
Medical management is the first line treatment in cases of detrusor instability. It consists of administration of parasympatholytics like oxybutanin or duoloxetine. Duoloxetine causes less dryness of mouth but is more expensive. These drugs are administered once a day and can be the only mode of treatment in pure detrusor overactivity. However, most patients have either a mixed picture or genuine stress incontinence. For these patients we need to supplement bladder drill, Kegel's exercises, use of weighted vaginal cones, vaginal estrogen administration for urogenital atrophy, prior to surgical correction.
Options for surgical management consist of both abdominal and vaginal procedures. Burch colposuspension is the procedure of choice in genuine stress incontinence. It is performed by a suprapubic incision by entering the cave of Retzius extraperitoneally and applying non-absorbable sutures between the vaginal vault and the ileopectineal ligament. It gives an immediate cure rate of 90% with a five-year cure rate of around 70%.98
Trans-vaginal Tape (TVT) and Trans-obturator Tape (TOT) are recently introduced procedures that employ non-absorbable proline mesh for lifting the urethra-vesical junction. They have the advantage of being less invasive, require shorter anaesthesia and can be performed as day cases. In comparative studies they give an 80-85% cure rate but long-term cure rate studies are still awaited.
Repair of cystocele and buttressing of bladder neck is not the procedure of choice when genuine stress incontinence is present as both the primary cure rate and the long-term cure rates are inferior to Burch colposuspension.
Other less frequently performed surgical procedures are Pereyra's needle suspension, Marshall Marketi Krantz (which can cause osteitis pubis) and other sling procedures. Collagen injections around the urethral meatus can be done if there is a short and patulous urethral opening. Insertion of an artificial sphincter can be done in cases of failure of primary Burch colposuspension.