Case Presentation

Naufa Azhari 071303053 F1

Patient profile

Name : Puan Anisah Binti Hussin Age : 35 years old Address : Sungai Rambai LMP : 6/4/2013 Parity index : Para 4 D.o.A : 16/4/2013 D.o.E : 16/4/2013

Chief concern

Elective admission for diagnostic laparoscopic bilateral cystectomy and dye test.

History of presenting concern

Patient was diagnosed to have bilateral ovarian cyst 3 years ago following complaint of severe cyclical lower abdominal pain (dysmenorrhea) during menstruation which then suggestive of endometriotic cyst. 7 month back ,it is also associated with heavy menses.

The pain started 1 day before menses, continue until day 3 or 4 which its relief gradually. The pain was again severe on the last day and following 2 days after stop menstruation. It is localize to groin and lower abdomen. The pain is so severe which affect her daily activity and cause her unable to go to work. She depends on analgesic to relief the pain but not make her free of pain. She seek medical attention from private hospital which detected bilateral ovarian cyst measuring 3cm x 3cm on the right side and 3cm x 2 cm on the left side. She was given analgesic to relief pain. No other investigation or follow up. Since then,the pain not reduce and regularly occur during menses. 7 month ago, she started having heavy menstrual bleeding from which soaked 6-7 pads per day and 3-4 pads at night. It is associated with flooding and passing clots. No complaints of breathlessness, syncopal attack, or easy fatigability. However her sleep was disturbed during period of mesntrual bleeding due to changing of pads.

She came to seek medical treatment in Melaka Hospital due to increase severity of the pain which she cannot tolerate it even with analgesic. 1st admission was on January 2013 where CT scan was done, shows bilateral large ovarian cyst which she was informed the shape look like kissing ovaries.She was given analgesic as she was not keen for any surgical intervention. Following follow up in march 2013, Ultrasounds was done which shows increase in size on both side of the ovarian cyst and abnormal position of uterus. In view of all the findings and previous CT scan, she was counselled for few options of surgical management which either conservative surgery or total removal of her reproductive organ and affected tissues as there is high chances of recurrence. She is not keen for the latter. She was well informed that there is high risk of recurrence of the disease in 2-3 years following conservative procedure. She also refused on any surgical intervention to the fibroid during this procedure.

Past obstetric history

Last child birth was 5 years ago.
Delivered full term baby via spontaneous vaginal delivery in 2000, 2002, 2005 and 2008.

No complications following delivery.

All children are healthy.

No history use of any contraception.

Menstrual history

She attained menarche at 12 years old Normally have 7 days of bleeding Cycle is regular 28-30days. Initially no dysmenorrhea. PAP smear done in 2011 in Pantai Hospital normal

Past history

Not significant

Family history

Mother passed away due to complication of breast carcinoma. Other family members Father - hypertension Sister - IHD

Personal history

She takes balanced diet, had normal bowel and bladder habit, sleep is normal. No known allergy. No drug abuse, non smoker and not consume alcohol.

Social history

She works as a teacher. Husband work as accountant. Household income is RM5000/month. She live with her husband and children in Sungai Rambai

General examination

Patient is alert, cooperative, moderately built, well nourished and comfortable in supine position. Height : 154 cm Weight : 60 kg BMI : 25.3 kg/m Vital signs : Pulse rate is 80 beats per minute, regular, normal volume, no special characteristic and bilaterally symmetrical. Blood pressure is 110/80 mmHg at left arm in supine position. Respiratory rate is 20 breaths per minute. Temperature is 37 Hands : No pallor Eyes: No pallor. Mouth: No pallor. Neck: No swellings, no lymph node enlargement. Breast: no lump or discharge Pedal edema: Not present

Abdomen examination

INSPECTION Abdomen is mildly distended especially in the lower abdomen.Flanks are full All quadrant move equally with respiration. Hernia orifices intact. PALPATION No tenderness. Abdomen is soft. No palpable mass. No organomegaly.

Percussion

Shifting dullness : not present

Normal bowel sounds heard

Auscultation

Investigations

Full blood count

Haemoglobin : 11.0 g/dL Other parameters are normal.

Normal CA 125 : 201.8 U/mL (<35.0) 11/1/2013 AFP : 1.1 ng/mL (<0.7) CEA : 0.9 ng/mL (<3.8)

Urine biochemistry

Tumor marker

CECT Thorax/Abdomen/Pelvis 29/1/2013 No pleural effusion. No lung nodule. No significant mediastinal lymphadenopathy. Fatty liver noted. No focal liver lesion. Spleen, pancreas, gall bladder, kidneys and adrenals are normal. Uterus is bulky with a bulging area seen at the posterior wall may represent isodense fibroid. Multiloculated cystic lesions seen in both adnexa

Left : 5.9 x 4.1 x 4.4 cm Right : 3.5 x 2.0 x 2.5 cm Presence of calcification at the wall of left adnexal cystic lesion and shows mixed echogenic content. There is fluid noted in pouch of Douglas.

No significant of pelvic or abdominal lymphadenopathy. No bowel related mass. No suspicious bony lesion.

Impression :

Bilateral adnexal multiloculated cystic lesions may represents endometriotic cysts. In view of raise CA 125>100, malignancy cannot be totally excluded.

Ultrasounds abdomen

Anteverted uterus. Multiloculated ovarian cyst :

Left : 6cm x 4cm Right : 4cm x 3 cm

Endometrial thickness : 3.3 mm Hyperdense tissue suggestive fibroid at posterior wall of myometrium measuring 5 x 3.7cm.

Plan in Hospital

Schedule operation as planned on 17/4/2013 Diagnostic laparoscopic bilateral cystectomy plus dye test, k.i.v proceed laparotomy. Inform anaesthesia department. Ask patient to fast. Allowed fluid only. Intravenous fluid given 4 pints 2pints normal saline and 2 pints dextrose 5% (given within 24 hours while nil by mouth)

Discussion

References

1. 2. 3. 4.

RCOG Green-top Guideline No. 41 Gynecology Today Acute and Chronic Pelvic Pain in Women by Bernard M. Karnath, MD A practical approach to problems in Gynecology for undergraduate by Professor Kulenthran Arumugam

Endometriosis

Endometriosis is the abnormal growth of cells (endometrial cells) similar to those that form the inside of the uterus, but in a location outside of the uterus

SITES
Ovary is the commonest site Spread is due to retrograde and lymphatic spread Size vary from spots to large chocolate cyst Inflammatory response can cause adhesions

Other Sites
Visceral peritoneum- scarring Anterior bladder adhesion Posterior dense adhesion POD obliteration Symptoms

Dyspareunia Dyschesia Alteration in bowel and bladder habits

Other Sites
Parietal peritoneum Infiltration of uterosacral ligament POD Rectovaginal septum Uterus becomes fixed and retroverted Symptom Deep dyspareunia

Other Sites

Involvement of anterior rectal wall and upper rectum Cyclical rectal bleeding (Haematochezia) Ileum,appendix and caecum may be involved- may lead to intestinal obstruction

Other sites
Rarely, endometriosis implants can occur outside the pelvis, on the liver, in old surgery scars, and even in or around the lung or brain.

Symptoms
1.

2.

The commonest symptom is dysmenorrhoea.The pain is very severe just prior to the period, last throughout the period and the pain will cease only at the end of period Chronic pelvic pain due to the involvement of peripheral spinal nerves

3. Deep Dyspareunia due to

Scarring of uterosacral ligaments Nodularity in rectovaginal septum Obliteration of pouch of Douglus Retroversion of uterus

4.

Rare symptoms of endometriosis include

Chest pain or coughing of blood due to endometriosis in the lungs Headache and fits due to endometriosis in the brain.

DIAGNOSIS

History

Dysmenorrhoea Dyspareunia Pelvic pain Menstrual irregularities Subfertility Other symtpoms depend on sites

EXAMINATION
Vaginal

examination - painful Bluish nodule in the posterior vaginal wall If chocolate cyst- adnexal mass

INVESTIGATION
Ultrasound examination

Chocolate cyst in the ovary Endometriosis in vaginal and bladder areas ruling out other pelvic diseases

MRI may be helpful to see the deposits in other sites- rectal involvement

INVESTIGATION

Laparoscopy is the gold standard of diagnosing endometriosis

a direct visual inspection inside of the pelvis and abdomen

TREATMENT

Medical treatment

Combined OCP

Suppress hypothalamic ovarian axis Prevents withdrawal bleeds and retrograde menstruation relief pain

Progesterone

Medroxyprogesterone acetate Either in the form of oral tablets or Depo Provera injection Shedding of endometrium Depo provera is easy to administer and more effective

Nonsteroidal anti-inflammatory drugs or NSAIDs

(such as ibuprofen or naproxen sodium) are commonly prescribed to help relieve pelvic pain and menstrual cramping. These pain-relieving medications have no effect on the endometrial implants.

Danazol

Danazol is a synthetic drug that creates a low estrogen hormonal environment by interfering with ovulation and ovarian production of estrogen. s/e : weight gain, androgenic features

Gestrinone

works in much the same way as danazol with similar, but milder, side effects.

Gonadotropin-releasing hormone analogues (GnRH analogues)

relieve pain and reduce the size of endometriosis implants. menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are available. The side effects are a result of the lack of estrogen, and include:hot flashes, vaginal dryness and osteopenia

Aromatase inhibitors

anastrozole and letrozole interrupting local estrogen formation within the endometriosis implants themselves. inhibit estrogen production in the ovary, brain, and other sources, such as adipose tissue. S/E :significant bone loss

Surgical treatment

Conservative surgery

for patient who want to have child Options : Tubal flushing Ablation of endometriotic lesion with adhesiolysis Laparoscopic ovarian cystectomy (if cyst > 4cm)

Kissing ovaries

Reference: http://www.gynae.com.sg/eng/gynaecology_cysts.html

Reference: http://www.gynae.com.sg/eng/gynaecology_cysts.html

 Radical

surgery

for women with very severe symptoms not responded to medical treatment or conservative operations. Total abdominal hysterectomy with bilateral salphingo-oophorectomy

Thank you