case presentation en dome trios is

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.

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