Obstetric Cases for MS-III

8/2/2019 Obstetric Cases for MS-III

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WESTERN UNIVERSITY OF HEALTH SCIENCES

2010

Core Obstetrics and

Gynecology clinical casesPart I Obstetrics

Lo n y C. Ca stro, MD, FA COGSpecialist, Maternal-Fetal MedicineProfessor and Chair, Dept of Obstetrics and GynecologyCOMP/Western University of Health Sciences

3 0 9 E . S E C O N D S T . , P O M O N A , C A . 9 1 7 6 6


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October 1, 2010

Message from the Chair

Dear Faculty and students,

The following cases were developed by the OB-GYN department at

Western University to be used as a basis for standardizing small

group discussions between students and faculty at each of our

different teaching sites during the core Ob-Gyn rotation.

The questions that follow each case are all based on the APGO

Learning Objectives for Medical Students (9th edition). The entire

case series covers all the major Ob learning objectives. This case

series emphasizes continuity of care from the preconception

period to the post partum visit and illustrates how much can be

learned from one patient. For this reason a few topics that are

traditionally considered gynecology and not obstetrics are also

included.

We hope you will find them educational and enjoyable.

Please feel free to email any comments suggestions about the cases

to me ([email protected]).

Sincerely,

Lony Castro, MD

Lony C. Castro, MD, FACOG

Specialist, Maternal-Fetal Medicine

Professor and Chair, Dept of Obstetrics and Gynecology

COMP/Western University of Health Sciences
mailto:[email protected]:[email protected]:[email protected]


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Suggested reference sources for study questions:

The Association of Professors of Gynecology and Obstetrics(www.apgo.org) : excellent student and faculty resource for

learning objectives, didactic cases, a test band (uwise) and

information of Ob-gyn residencies

US preventive health services and screening guidelines:www.USPreventiveServicesTaskForce.org

WHO contraception guidelines: www.who.org(go to health topics and search contraception)

Up to Date:www.utdol.comand search appropriate topic

The National Institute of Child Health and HumanDevelopment:www.nichd.gov and the National Institutes of

Health www.nih.gov ---for pubmed, latest research andguidelines for pregnancy, neonatology and womens health etc

The Centers for Disease Control for STI (or STD) guidelines:www.cdc.gov(go to publications and MMWR where you will

find the 2006 STD guidelines)

The American College of Obstetrics and Gynecologywww.acog.orgfor committee opinions and practice guidelines

related to most clinical topics in Ob-Gyn. These are allcompiled in the 2010 Compendium (available in the library orthrough all preceptors/clerkship directors). These publications

are also available the Obstetrics and Gynecology (The Green

Journal) website:www.greenjournal.org

Beckmann-Obstetrics and Gynecology-6th ed

Hacker and MooreEssentials of Obstetrics and Gynecology-5th ed, 2010

Williams Obstetrics-23rd ed
http://www.apgo.org/http://www.apgo.org/http://www.apgo.org/http://www.uspreventiveservicestaskforce.org/http://www.uspreventiveservicestaskforce.org/http://www.who.org/http://www.who.org/http://www.utdol.com/http://www.utdol.com/http://www.utdol.com/http://www.nichd.gov/http://www.nichd.gov/http://www.cdc.gov/http://www.cdc.gov/http://www.acog.org/http://www.acog.org/http://www.greenjournal.org/http://www.greenjournal.org/http://www.greenjournal.org/http://www.acog.org/http://www.cdc.gov/http://www.nichd.gov/http://www.utdol.com/http://www.who.org/http://www.uspreventiveservicestaskforce.org/http://www.apgo.org/


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OBSTETRICSCLINICAL CASES

CASE NUMBER ONE

Topics covered: Comprehensive womens medical interview and exam,

recommended age appropriate heath care screening measures, generating a

problem list, formulating a diagnostic impression and plan (including diagnostic

studies, treatment and patient education), counseling regarding substance use,

nutrition, exercise, medication and immunizations (with emphasis of preconception

counseling), diagnosis and management of vaginitis, STI screening, how pregnancy

affects common medical conditions and how these conditions affect pregnancy,

common infections and potential impact on fetus/neonate.

Presenting Complaint: Maria Espinosa ( M.E.) is a 32 year old hispanic female

gravida-1, para-0, ectopic-1 with a history of diabetes mellitus who presents to youroutpatient medical clinic for an annual exam. She complains of a white vaginal dischargeassociated with itching and dysuria. She has a past history of vaginal yeast infections.

She has no fever, abdominal pain or flank pain. She is using combined oral contraceptive

pills for birth control. Her LMP was 3 weeks ago but she occasionally has irregularmenses. She states she has a past history of genital herpes but has not had an outbreak in

over two years. She denies any other history of STIs (sexually transmitted infections) or

medical problems and has no past history of abnormal pap smears. She and her husband

have been married for five years and would like to have children. She is concerned aboutthe impact of diabetes on the pregnancy and wants to know what she can do to optimize

her chances of having a normal pregnancy and healthy infant. She works as a preschool

teacher and inquires if this job is safe for her to do once she becomes pregnant. She isalso concerned about her weight and questions you regarding the need to lose weight

before becoming pregnant.

Past Medical History: She was diagnosed with diabetes mellitus five years ago and is

currently trying to control her blood sugars using oral hypoglycemics and diet. Her

hemoglobin A-1C at the time of her last exam was 7.2 mg%. She occasionally checksher fasting blood glucose with a glucometer and states it is usually around 100.

Past Surgical History: laparoscopic removal of unruptured tubal pregnancy

Gynecologic History: menstrual history: onset at age 12, currently regular, lasting 5

days occurring at 28-30 day intervals. Pregnancy History: previous ectopic pregnancy at

age 18. History of STIs per above.

Social/Occupational History: As per presenting compliant. She denies tobacco or illicit

drug use. She drinks an occasional glass of wine with dinner.


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Family History: Her parents are alive. Her father is a diabetic and her mother has

chronic hypertension. She has one brother and two sisters. There is no history of mentalretardation or birth defects in her immediate family.

Medications: glyburide, combined low dose oral contraceptives

Allergies: none known

Physical Exam:Her vital signs are as follows: Temp: 37.2; Resp: 18; BP: 122/74; HR: 78

Body Mass Index: 30

General physical examno apparent abnormalities other than obesityNeckno thyromegaly

Chestlungs clear to auscultation

Heartregular rate and rhythm without murmurs or gallops, the PMI is not displaced

Breast Examno masses or dischargeAbdomennontender, without guarding, no palpable masses, normal active bowel

soundsBackno CVA tendernessExtremitiesno clubbing, cyanosis or edema

Pelvic Exam---external genitalia appear normal; vagina: pink, normal rugae, with a thick

white adherent discharge (whiff test negative, ph less than 4.5); cervix: the os is closedwith no significant discharge and there are no lesions visible; uterus: normal size shape

and consistency; adnexa: non-tender and no masses are palpable; rectovaginal: no masses

felt. At the time of the pelvic exam you collect samples for a pap smear and wet mount.

Study Questions:

1) Write out an assessment (problem list/diagnoses) and plan for this particularpatient based on the information given above.

2) Using current US Dept. of Health Services Guidelines: List generallyrecommended age-appropriate screening procedures and recommended time

intervals (in women) for mammograms, bone density screening, Pap tests, STIevaluation, immunizations and other screening tests. Which (if any) of these tests

are appropriate for the patient described above?

3) List the common causes of vaginitisdescribe the clinical and wet mountfindings (characteristics of discharge, ph, whiff test and microscopy) for each, therole of cultures (if any) and a preferred treatment regimen for each. For the above

patient the wet mount shows budding yeast and hyphae. What is your diagnosis

and recommended treatment plan?4) Describe how certain common medical conditions (obesity, diabetes mellitus,

urinary tract infections, chronic hypertension, cardiac disease, and asthma) affect

pregnancy and if pregnancy exacerbates these conditions.5) For the patient above: which medical conditions does she have that might affect

her pregnancy outcome? What do you advise her to do in the preconception


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period to control/treat these conditions with the goal of helping her to have the

healthiest pregnancy/baby possible. Address medication, nutritional (includingvitamin supplementation), educational and lifestyle issues. What hemoglobin A-

1C level and fasting blood glucose levels should this patient aim for if she wants

to become pregnant? Are these goals the same as for non-pregnant adults?

6) This patient reports occasional alcohol use. How do you screen for excessivealcohol use? How can alcohol use affect pregnancy outcome? What are the signsof fetal alcohol syndrome?

7) Discuss in general terms the effects of tobacco use and illicit substance use(opiates, cocaine, methamphetamines) on pregnancy outcomes?

8) Is this patient on any prescription medications that might adversely affect apregnancy outcome if she conceived on them? Which medications for diabetes

are considered safe in pregnancy? Be familiar with the FDA classification of

drugs in pregnancy. List some commonly used medications (anti-hypertensives,

agents for blood glucose control, etc.) that should not be prescribed to a womanwho is pregnant or who might become pregnant while using them.

9) Does this patient have any occupational hazards in terms of pregnancy outcome?10)Is this patient at risk for any sexually transmitted infections (STIs)? Which oneswould you screen for and how would you screen (i.e. history, exam, lab,

cultures?).

11)If this patient becomes pregnant, is her fetus at risk for any congenital infections(based on the history presented)? Which infections are possible and how could

they affect the fetus/neonate. What (if any) can be done to prevent the fetus from

acquiring these infections?

12)Should you check this patients immune status for certain viral infections? If sheis found to be rubella non-immune what should you do?

13)Discuss how the following infectious diseases (herpes, syphilis, gonorrhea,chlamydia, rubella, group b strep, hepatitis, cytomegalovirus, toxoplasmosis,varicella zoster, parvovirus, human immunodeficiency virus and human papilloma

virus could affect the fetus/newborn as well as the impact of pregnancy on these

infections (if any).

14)Now that you have answered the above questionsre write your assessment andplan for the above patient---in the plan be sure to include patient educationalissues including nutritional and lifestyle issues as well as lab tests and

medications.

15)The history given for this case was meant to be a comprehensive womansmedical interview/history. Were some key areas left out? Provide someexamples of how you might elicit a sexual history from a patient. What could be

some screening questions you might include regarding domestic violence? If you

did identify a patient involved in a situation where she is exposed to domesticviolence, how would you counsel her for short-term safety? Cite the prevalence

and incidence of violence against women, elder abuse and child abuse.

16)When should M.E. return for a follow-up visit? Be preparedyou will followthis patient for some time!


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CASE NUMBER TWO

Topics covered: acute abdominal pain, first trimester bleeding, spontaneous

abortion, ectopic pregnancy, ovarian cyst, adnexal torsion

Presenting Complaint: M.E. presents to the local Urgent Care Clinic one year later and

you are paged to evaluate her. Her LMP was about 7 weeks ago and she is having

vaginal spotting and right-sided lower abdominal pain with cramps with nausea. Thepain began acutely about 24 hours ago and is getting worse. She denies fever, chills,

vomiting, dysuria or back pain. She denies passage of tissue, blood clots or vaginal

discharge. She describes the pain as similar to the pain she had with her ectopic

pregnancy. She has been off OCPs because she has been trying to conceive. She hasbeen using insulin to control her blood glucose based on your previous recommendation.

She states a home pregnancy test was positive.

Physical exam:

BP: 110/68; HR: 92; Resp: 22; Temp: 37 deg. CAbdomen: non-distended without rigidity. There mod-severe right lower quadrant pain

with some guarding but no rebound. Bowel sounds are normal.

Back: no CVA tenderness

Pelvic: Speculum exam: ext genitalia appear normal; there is a small amount of blood inthe vaginal vault. The cervical os is closed with some bleeding coming from the os. No

lesions are seen. Bimanual exam: The uterus is soft and minimally tender. The right

adnexa is moderately to severely tender and there is a suggestion of a mass. The leftadnexa is nontender and no mass is palpable.

General physicalheart/lungs/extremitiesnon contributory

Study Questions:

1) Based on the information given above (and taking into account your review ofM.E.s medical record and your previous history and physical described in case

no. 1) list a differential diagnosis for acute abdominal pain in a reproductive aged

woman. List a differential diagnosis for first trimester bleeding and abdominalpain. What are the 2-3 most likely diagnoses for this particular case?

2) Do you think any key information was left out of the history and/or physical examthat would help you in deciding on the correct cause of her abdominal pain and

bleeding? (e.g.Do you think any questions screening for domestic violence are

indicated? Should postural vital signs or a rectovaginal exam have been done?)


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3) What laboratory or imaging studies do you think are most essential in order foryou to finalize your diagnosis and formulate your management plan?

Case Two continued: Next you order a CBC, urinalysis, serum glucose, a quantitative

beta hCG and a pelvic ultrasound.Results: hemoglobin: 12 gm/dl, hematocrit: 36%; glucose: 80 ; UA: dipstick is negative,

microscopic shows many epithelial cells, a few WBCs and 1+ bacteria. The serum betahCG 800. The pelvic ultrasound shows no evidence of an intrauterine pregnancy and a 4

cm cystic right adnexal mass. There is no fluid in the cul-de-sac.

Study Questions:

4) Did the additional laboratory and ultrasound studies alter your most likely

diagnosis?

5) What are your next steps in managing this patient---(Does she have to beadmitted or can you manage her as an outpatient? Do you need more lab tests orcultures? Do you want to follow her, prescribe any medication or is any type of

surgical procedure indicated?)

6) Should you order a type and screen on this patient? What would you do if she is Rh

negative? (This issue is discussed in more detail in the next case.)

7) Discuss in general terms the risk factors for ectopic pregnancy and how to evaluatea patient suspected of having an ectopic pregnancy.

8) Discuss how one differentiates the different types of spontaneous abortion.


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CASE NUMBER THREE

Topics covered: diagnosis of pregnancy; assess gestational age; distinguish an at-

risk pregnancy; obstetric history and physical; maternal anatomic and physiologic

changes associated with pregnancy; effect of pregnancy on common diagnosticstudies or laboratory tests; maternal serum AFP; diabetes in pregnancy;

hypertensive diseases in pregnancydefintion/classification, symptoms, physical

signs and common laboratory findings associated with preeclampsia/eclampsia;

third trimester bleeding; preterm labor; stages of labor; the labor graph; fetal

heart rate tracings; hemolytic disease of the newborn and use of Rh

immunoglobulin prophylaxis; post-partum fever; endometritis

New Ob Visit: M.E. returns to your office. She is now 14 weeks since her LMP. She is

here for a new ob-visit. She is currently using insulin to control her blood sugar and istaking prenatal vitamins. The vaginal bleeding and pain she experienced earlier have

resolved. (Your final diagnosis was threatened abortion with a ruptured corpus luteumcyst.) She does not yet feel fetal movements. She has no specific complaints but isanxious to know that things are progressing normally. On exam: vital signs: BP is

100/60, HR is 88; Resp are 20 and she is afebrile. Her BMI is 30. Pertinent findings on

physical exam are as follows: neck: thyroid slightly enlarged; Breasts: without masses ordischarge; Cardiac: normal rate and rhythm with a II/VI systolic ejection murmur on the

left sternal border. Abdomen: uterus palpable just above the symphysis pubis and fetal

heart tones in the 150s with Doppler; Back: without CVA tenderness; extremities

without edema. Pelvic exam: speculum exam: external genitalia and vagina are withoutlesions or discharge. There is a small amount of mucus coming from the cervical os but

no cervical lesions are noted. On bimanual exam the uterus is c/w 14 week size and there

are no adnexal masses. At the time of the pelvic exam you obtain a pap smear, gonorrheaand chlamydia cultures. You inform the patient of your exam findings and tell her that

her gestational age is 14 weeks. You assign a due date and review again the factors that

put her pregnancy at risk (diabetes, obesity, history of herpes---ANYTHING ELSErefer to cases one and two to refresh your memory.)

Study Questions:

1) What are the components of an initial new ob history and physical? ( In the abovecase the history and physical are somewhat abbreviated because you did a complete

history and physical on M.E. a year agois this appropriate?).2) List the standard obstetric diagnostic studies done on most pregnant women at the

time of the new ob visit, at 15-19 weeks at 24 -26 weeks and at 35-37 weeks

gestational age.3) How do you diagnose a pregnancy? What are some common early symptoms and

physical signs suggestive of pregnancy?

4) How do you date a pregnancy? What is the range of error in the ultrasounddetermination gestational age in the different trimesters of pregnancy?


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5) Where should the uterus be on abdominal exam at 12-13 weeks, at 20 weeks and at34 weeks? What should the fundal height measure at each of these gestationalages?

6) Describe the anatomic/physiologic changes induced by pregnancy on the thyroidgland, the heart, the peripheral vasculature and vital signs (respiratory rate, heart

rate, blood pressure)? How does pregnancy affect the respiratory system and renalsystem?

7) What affect (if any) does pregnancy have on the following laboratory studies:CBC, serum electrolytes, BUN, creatinine, 24 hour urine protein, AST, ALT,

alkaline phosphatase, TSH, total T-4, total T-3, free T-4 and free T-3. What is the

clinical significance of the fact that pregnant women have a compensatedrespiratory alkalosis?

8) Generate a problem list for M.E. to put on the front of her pernatal record.9) What do you advise M.E. regarding nutrition, exercise and weight gain during

pregnancy?10)What are your target pre-meal and one hour post-prandial blood glucose values?

11)What specifically do you tell her about the impact of diabetes on her pregnancyoutcome?12)What additional studies (ie non-routine) do you advise for M.E.?

Case Three continued: M.E.s prenatal studies come back normal, except for the fact

that her quadruple screen shows an elevated serum AFP value and her blood type is RH

negative and her antibody screen is negative.

Study Questions:

12). Which hormones are part of the quadruple screen? What is the significance of anabnormal serum AFP or an abnormal quadruple screen? (i.e. what

fetal/placental/maternal factors could cause the abnormality). What would you do next

to evaluate an abnormal AFP or abnormal quadruple screen?

13). When should M.E. get rhogam (RH immune globulin)? Discuss the general

settings in which rhogam should and should not be administered to an Rh negativewoman. What would you do if she was Rh negative, antibody screen positive?

14) Can other antibodies besides the Rh antibodies cause hemolytic disease of the

newborn? If M.E. was Rh positive and had a positive antibody screen would this because for concern? What would you do to evaluate this?. Discuss the potential

significance of antibodies to Kell, Duffy, Lewis A and Lewis B.

Case Three continued: M.E.s pregnancy progresses well. She receives rhogam at 28

weeks and she is able to control her blood sugars on twice a day insulin. You follow thefetus closely with ultrasounds and begin NSTs at 32 weeks. Her pregnancy progresses

well until 35 weeks when she presents to labor and delivery complaining of cramps,


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vaginal bleeding, swelling of her hands and feet and a headache. She is found to have a

Bp of 160/110, urine dipstick showing greater than 300mg/dl of protein. She has 3 plusedema of her legs and hands. Her fundal height is 35 cms. She is having regular

contractions and the fetal heart rate monitor shows a baseline fetal heart rate of 150 bpm

with normal reactivity and no decelerations. An ultrasound shows a 2500 gm fetus with a

posterior placenta and no previa. A pelvic exam shows the cervix to be soft but notdilated. You send off some laboratory tests which all come back normal.

Study Questions:

15). What new problems has this patient developed? What is/are your diagnoses at thistime?

16). What are the major causes of third trimester bleeding? What are the signs and

symptoms associated with these causes?

17). If this patient was hypotensive from significant blood loss what would your initialmanagement plan consist of?

18). What are the definitions of hypertension in pregnancy? What are the symptomsand physical signs of pre-eclampsia-eclampsia? What symptoms, signs and laboratoryalterations might be indicative of severe disease?

19).How do you make the diagnosis of labor? What is the definition of preterm labor?

Did M.E. have preterm labor?20). What are the definitions of the three stages of labor? What are some common

labor abnormalities? Sketch an example of a normal labor graph and an abnormal

labor graph.

Case Three Continued: You decide that M.E. has severe preeclampsia and you are

concerned that she might be having a placental abruption. You start an intravenous line,administer magnesium sulfate for seizure prophylaxis and lower her blood pressure with

IV hydralazine. A repeat pelvic exam reveals that the cervix is now 3 cms dilated. The

fetal heart rate tracing develops repetitive deep smooth decelerations that come after thepeak of the uterine contractions. They do not resolve with oxygen, maternal position

change or cautious hydration. You decide to proceed with a cesarean section for a non

reassuring fetal tracing. The surgery is uncomplicated and you deliver a 2600 gram babyboy with apgars of 8 at one minute and 9 at five minutes. In the immediate post partum

period she does well. Her insulin requirements decrease and her blood pressure returns

toward pre-pregnancy values. You stop the magnesium sulfate about 24 hours after

delivery. She requires another dose of rhogam because the baby is Rh positive. You tryto encourage her to breast feed. On post-partum day number three she develops a

temperature to 101 deg. F. On exam she is tachycardic with a Bp of 120/70. Her uterus

is very tender and the lochia is foul smelling. The incision does not appear to beindurated or erythematous.


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Study Questions:

21). What features do you look at when assessing a fetal heart rate tracing? Describe

some common normal and abnormal fetal heart rate tracings. What is the significance

of the three different types of decelerations? Do you agree with the management in thecase above?

22).What are the common causes of post-partum/post cesarean section fever? How dothey present?

23). What are some of the key aspects of the history and physical exam that should be

included in the work up of any patient with a post-partum fever? What laboratorystudies (if any) would you do on the above patient?

24). What is your presumptive diagnosis in the above patient? How would you treat

her?

CASE NUMBER FOUR

Topics covered: Postpartum depression, cervical disease and neoplasia,

contraception and sterilization

Post Partum check-up: M.E. returns to your clinic for a six week post partum check-up.She states she has been feeling very tired and often finds herself crying and feeling that

that caring for the baby is overwhelming. He husband is supportive but works long

hours and is not home much. M.E. feels isolated at home but does not feel ready toreturn to work and has requested an extended leave of absence. She is breastfeeding her

infant and the mastitis you treated her for previously has resolved. She denies any

abnormal vaginal bleeding, dysuria or urinary incontinence and has not yet had a returnof her menses. She and her husband have not had sexual intercourse since the birth of

their child. M.E. is anxious to have a reliable method of contraception prescribed and

would like to know what options she has. She has heard that it is not safe for the babyto use birth control pills while breast feeding. She is still taking her prenatal

multivitamins and continues to use insulin to control her diabetes.

Pertinent findings on physical exam are a blood pressure of 128/78, heart rate of 82 and aBMI of 29. Her thyroid gland is not enlarged, the breast exam reveals no discreet masses

and milk is expressed from both nipples. The abdomen is non-tender without palpable

masses. Pelvic exam: The external genitalia appear normal without any evidence ofprevious laceration; speculum exam reveals no lesions, bleeding or abnormal discharge in

the vagina although the rugae appear pale and somewhat atrophic. The cervical os is

closed without lesions. Bimanual exam shows no evidence of cervical motiontenderness. The uterus is minimally enlarged and non tender. There are no palpable


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adnexal masses. The rectovaginal exam shows the sphincter to be intact. You send a pap

smear (thin prep) and a fingerstick to check her glucosea random blood glucose is 120.

Study Questions:

1) If you were writing the progress note in this patients chart whatproblems/diagnoses would you list under Assessment?2) What are some risk factors for post partum depression? Do any apply to M.E.3) How do you diagnose post-partum blues, depression and psychosis? Do you

think M.E. has post-partum depression? What additional questions could you ask

to clarify the diagnosis?4) Are there any additional diagnostic tests you think M.E. should have? (Does she

need a CBC, thyroid function tests or pregnancy test? Does she need any other

studies?)

5) Describe the physiologic basis of the following contraceptives: combinedhormonal oral contraceptives (COCs), progesterone only oral contraceptives

(POPs), intramuscular depomedroxyprogesterone acetate (DMPA), intrauterinedevices (IUDs), combined contraceptive patch and ring, barrier methods, maleand female sterilization.

6) Describe the effectiveness of each of the above forms of contraception.7) For the contraceptive methods listed in question fivereview the WHO

guidelines and determine which are safe, which are relatively contraindicated and

which are absolutely contraindicated for each of the following medical conditions:

diabetes mellitus, hypertension (controlled vs uncontrolled), ischemic heart

disease, current or past episode of venous thromboembolic disease, family historyof venous thromboembolic disease, migraine headaches, gallbladder disease,

history of STIs (sexually transmitted infection), cervical cancer, and breast

cancer.8) Which method or methods do you think would be best for M.E.?How would

you counsel her about the benefits and risks of each form of contraception?

Case Four continued: After extensive discussion you refer M.E. to a licensed clinical

social worker for further counseling and administer an IM injection of DMPA for

contraception. One week later her pap smear returns as low grade squamousintraepithelial lesion (LSIL). You have your office staff call her to make a follow-up

appointment to discuss the results of the pap smear and your management plan.

Study Questions:

9) Identify the common clinical risk factors for cervical dysplasia and cancer. DoesM.E. have any of these risk factors?

10)What is the difference between a thin layer pap smear and a conventional papsmear? What are the benefits (if any) of a thin layer pap smear- in general and in

the case of M.E?11)Describe the different abnormalities one can obtain on a pap smear?

Describe the initial management plan of a patient with an abnormal pap smear.

Documents

Obstetric Cases for MS-III