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8/3/2019 Case Presentation En Dome Trios Is
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Leah Orta, MS IIIOB/GYN ClerkshipDr. Flix Hernndez RodrguezDr. Miguel Vega Gilormini
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Discuss the patients gynecological and obstetric
history
Present the findings of the Exploratory Laparoscopy
performed on the patient
Define Endometriosis
Discuss the epidemiology, etiological theories,symptoms, diagnosis, and management of
endometriosis
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Patients OB/GYN History
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Age: 30 y/o
Sex: Female
Ethnicity: Puerto Rican
Civil Status: Married
Town of Residence: Ponce, PR
Occupation: Pharmaceutical representative
Religion: Roman Catholic
Source: Patient: Reliable
Admission Date: 10/23/09
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Chief Complaint:
Pelvic pain of more than 5 years duration
History of Present Illness:
Case of 30 y/0 female G2P1A1 LMP unknown who presents with chronicpelvic pain of more than 5 years duration and failure to conceive for the
past year. The patient reports heavy bleeding during menses, moderate
to severe pelvic pain associated with menstruation, and deep pelvic pain
during sexual intercourse. Pain is generalized with a dull quality (5-6/10)that progresses to stabbing and tearing quality (10/10) during menses,
and it is relieved with use of NSAIDs and aggravated with menstruation.
Patient denies history of chlamydia, gonorrhea, or other STIs. The
patient had not undergone evaluation prior to her presentation.
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Past Medical History:
Medical conditions:
GIT: Gastritis, Reflux
CNS: Migraine
Hospitalizations: Delivery
Surgical procedure: None
Medications: None
Allergies: None
Transfusions: None
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Family History: Non-contributory
Social History:
Married with 1 child
Actively working
Habits: None
Review of Systems: Non-contributory
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Vital Signs:
BP: 113/61 mmHg T: 37.0C P: 80 bpm R: 18 breaths/min
Ht: 5 2 Wt: 137 lbs BMI: 25.1
General appearance: Calm, alert and oriented. () diaphoresis
Skin: (-) jaundice, (-) rash, (-) ecchymoses, (-) petechiae
HEENT: Face is symmetric; eyes and pupils are symmetric; teeth are
intact
Neck: No pain or weakness during neck movements. Carotid pulse felt,
no bruits heard.
Shoulders and Back: (-) Jordan Sign, symmetrical movement
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Thorax:
Costovertebral joints: No tenderness or pain
Heart: Regular rate and rhythm. No murmurs, rubs, or gallops
Lungs: Clear to auscultation bilaterally
Breasts: No masses or nipple discharge
Abdomen: Flat, non-tender abdomen. No bruits heard. Bowel sounds
present.
Pelvic: Pelvic exam under anesthesia revealed anteverted uterus, posterior
cervix, and uterine size of 8cm
Extremities: All pulses felt bilaterally. (-) edema
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Differential Diagnosis (+) (-)
Endometriosis AgeDysmenorrheaDyspareunia
InfertilityPain relieved by NSAIDs
No prior directobservation studies toconfirm presence of
endometrial implants
Pelvic InflammatoryDisease
AgeGeneralized pelvic painInfertility
Negative history of GC orchlamydia
Primary Dysmenorrhea AgePain associated withmenses
Associated symptomsincluding dyspareuniaand infertility
Irritable Bowel Syndrome AgePelvic PainDyspareunia
Negative history of smalland/or large bowelsymptoms
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Diagnostic Findings
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Abdominal cavity was entered through umbilical incision and pelvic
cavity visualized through video laparoscopy
Left ovary was immediately evident:
Left and right fallopian tubes were visualized and seen to be adherent to leftovary
Right ovary was not visualized
Left ovary was punctured and drained
Chocolate-colored fluid exited the left ovarian cyst
Endometrioma capsule was removed and sent for pathology
Cromotubation was performed using methylene blue dye: both
tubes were patent
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Left Ovary and Uterus Left Ovary andLeft Fallopian Tube
EndometriomaPunctured
EndometriomaCapsuleRemoved
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Preoperative Diagnosis: Chronic Pelvic Pain
Postoperative Diagnosis: Endometriosis
Procedure: Operative Triple Puncture Video Laparoscopy with Left
Ovarian Cystectomy and Cromotubation
Physician: Dr. Miguel Vega Gilormini
Estimated Blood Loss: 100ml
Drains: None
Complications: None
Specimen: Left Ovarian Endometrioma Capsule
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Source:
Endometrioma, capsule
Gross Description:
Left endometrioma; specimen consists of few irregular
fragments of brown, soft tissue measuring in aggregate 3.5
x 3 x 0.6 cm.
Final Diagnosis: Microscopic diagnosis:
Endometrioma
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Definition, Epidemiology, Etiological Theories,
Symptoms, Diagnosis, and Management
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Definition:
The presence of endometrial glands and stromaoutside of the uterine cavity [1]
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Prevalence[2]:
Worldwide: 90 million women suffer from endometriosis
USA: 5-7 million women (1 in 10)
PR: 5% of PR women (1 in 20)
Overall, found in:
3-10% of women of reproductive age
25-35% of infertile women
Peak Age Group: 20-40 year olds
Prevalence is not affected by ethnicity or SES
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Implantation Theory:
Retrograde reflux of menstrual tissue from thefallopian tubes during menstruation
Most widely accepted theory
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Celomic Metaplasia Theory:
Mesothelium covering ovaries invaginates into the
ovaries, then undergoes metaplasia into endometrial
tissue
Embryonic Rests Theory:
Mllerian remnants in the rectovaginal region
differentiate into endometrial tissue
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Having a first line relative
with endometriosis (7-9x
increased risk)
Shorter menstrual cycles
Longer bleeding duringmenstruation
Early menarche
Environmental exposure
to dioxins (pollutants)
Consuming 1 or more
alcoholic drinks per week
Use of pads ANDtampons
Never using OCPs
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Symptoms are non-specific and they tend to be strongest pre-
menstrually, subsiding after cessation of menses. These
include:
Generalized pelvic pain: most common symptom
Back pain
Dyspareunia: pain with sexual intercourse
Loin pain Dyschezia: pain with defecation
Pain with micturition
Infertility
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Dysmenorrhea Dyspareunia Pelvic Pain Infertility
Primary: due to
imbalance betweenPGE2 and PGI2
Diminished lubrication or
vaginal expansion due todecreased arousal
Endometritis Anovulation
Adenomyosis GIT causes: IBS, constipation Neoplasms Cervical factors:mucus, stenosis
Myomas Infection Nongynecological Male infertility
Infection Musculoskeletal causes: levator
spasm, pelvic relaxation
Ovarian torsion Luteal phase
deficiency
Cervical Stenosis Pelvic vascular congestion Pelvic adhesions Tubal disease or
infection
Urinary causes: interstitial
cystitis
PID
Sexual or physical
abuse
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Physical limitations to conducting household
chores, sexual relationships, work, exercise, social
activities, and childcare.
Decrease in the quality of work due to symptoms
Absenteeism: on average 33. days per year
Truncated career growth due to absenteeism anddecreased quality of work
Changes in appetite
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Direct visualization of lesions with histological confirmation is
the gold-standard
Positive histology confirms the diagnosis, but negative
histology does not exclude it
Histological examination should confirm the presence of at
least two of the following features:
Hemosiderin-laden macrophages
Endometrial epithelium
Endometrial glands
Endometrial stroma
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[2]
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White plaques &Clear vesicles
Blue-blacklesions
Newly formedblood vessels
[2]
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[2]
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Physical Examination:
Tender nodules in the posterior vaginal fornix
Uterine motion tenderness
A fixed and retroverted uterus
Tender adnexal masses resulting fromendometriomas
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Imaging:
Transvaginal ultrasound (TVS) has no value in diagnosing
peritoneal endometriosis, but it is a useful tool both to
make and to exclude the diagnosis of ovarian
endometrioma and retroperitoneal and uterosacral lesions
MRI has limited value as a diagnostic tool: it is more useful
for the diagnosis of an endometrial cyst
CT Scan has not been studied or promoted as a diagnostic
imaging modality
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Serum markers:
CA 125:
Best known for its use in the diagnosis or monitoring of
ovarian cancer
Useful marker for endometriosis monitoring and
treatment follow-up
Elevations over 35 IU per ml are considered suspicious for
endometriosis when correlated with symptoms
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Serum markers:
CA 19-9:
Inferior sensitivity to CA 125, but may be of some use in
determining disease severity
IL-6:
At a cutoff value of 2pg/mL, may be more sensitive and specific
than CA 125
TNF-:
With elevations in the peritoneal fluid, has a sensitivity of 1 and
specificity of 0.89.
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Endometriosis suspected basedon history and physical
examination
Fertility notdesired
OCPs orProgestogens
If no improvement:
GnRH analogues
If no improvement:Laparoscopy and surgical
treatment
If no improvement:
Hysterectomy and
oophorectomy
Infertility with othercauses ruled out
Laparoscopy
Surgical Excisionof lesions
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Depot MDPA (Depo-Provera)
MDPA (Provera)
Combined OCPs
Levonorgestrel IUD (Mirena)
GnRH analogues (Lupron, Zoladex)
Nafarelin (Synarel)
Danazol
Gestrinone
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Defined as failure to conceive for 1 year while having
unprotected sexual intercourse
Management in patients with endometriosis includes: Ovarian Stimulation
Intrauterine Insemination: improves fertility in minimal to
mild endometriosis, especially with ovarian stimulation
In-vitro Fertilization: appropriate when tubal function is
compromised, male factor infertility is present, and/or other
treatments have failed
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1. Mounsey, AL, Wilgus, A, & Slawson, DC. Diagnosis and Management of Endometriosis.
American Family Physician 2006; 74.4: 594-602.
2. Flores, I. 2009.Endometriosis: La enfermedad enigmtica. [Powerpoint slides] . Retrieved
from Ponce School of Medicine on October 26, 2009.
3. Fourquet, J, Gao, X, Zavala, D, Orengo, JC, Abac, S, Ruiz, A, Laboy, J, & Flores, I. Patientsreport on how endometriosis affects health, work, and daily life. NIH-PA Author
Manuscript. 2009. Retrieved from Ponce School of Medicine on October 26, 2009.
4. Kennedy, S, Bergqvist, A, Chapron, C, DHooghe, T, Dunselman, G, Greb, R, Hummelshoj,
L, Prentice, A, & Saridogan, E. ESHRE guideline for the diagnosis and treatment of
endometriosis. Human Reproduction. 2005; 1-7.