K Raja/N Varol FPA FPA Sydney August

Transcription

1 FPA Sydney August

2 Ms wilson 32 year old woman Presents with worsening, heavy menstrual and intermenstrual bleeding and pain for 6 months.

3 Ms Wilson What is the differential diagnosis What are the most important questions to ask in history taking. What are the most important investigations which would help in deciding management/treatment options.

4 Ms Lee 41 yr G2P2 presented for Pap smear Pelvic examination 14 wk size uterus irregular. No adnexal mass palpated. No urinary /bowel symptoms, no pain or abnormal bleeding, regular periods Pelvic ultrasound showed 14X9.0X6.0 cm uterus with multiple fibroids, normal ovaries.

5 Adenomyosis Under reported on imaging Has potential to cause similar symptoms/signs to fibroid disease.

6 Multiple fibroids Ssypmtoms and signs of fibroids are varied and depend on the size and location Menstrual symptoms Pressure symptoms Bladder Bowel ureteric compression DVT Malignancy Rare but be vigilant in rapidly growing large fibroids and heavy abnormal bleeding

7 Best course for management Observation/expectant (asymptomatic or minimal symptoms) Medical management Myomectomy/open/Laparoscopic/hysteroscopic Vaginal hysterectomy Laparoscopic/Abdominal hysterectomy Uterine artery embolisation MRgFUS (Magnetice Resonance guided Focused UltraSound )Ablation of uterine fibroids ( Royal women Melbourne). Causes coagulative necrosis of tissue

8 Indications for surgical intervention in fibroid disease Severe myoma related symptoms. Potential for compromise/pressure on adjacent organs if continues to grow The greater risk of surgical complications (if fibroids grow larger and need surgery) Improving fertility potential. Sub-mucosal and large multiple fibroids have negative impact Possibility of continued growth (younger women with large fibroids) Possibility of malignancy can not be excluded by imaging

9 Ms Jones 32 year old Gravida 0 presents with PV bleeding and abdominal pain. Trying for a pregnancy for last 5 years. Home pregnancy test positive.

10 What is the differential diagnosis What are the risk factors for a extra-uterine pregnancy Quantitative BHCG, serum progesterone and a Pelvic ultasound (preferably transvaginal) provide diagnosis in most cases.

11 Ectopic pregnancy

12 Cut section of the same pregnancy

13 Ectopic Pregnancy on Transvaginal ultrasound

14 Role of Ultrasound in early pregnancy assessment Ultrasound scan 1st test IUP 71% Abnormal IUP 18% Ectopic pregnancy 3% Non-diagnostic 8% diagnosis made at ultrasound on 1st visit in 92% cases

15 Management of ectopic pregnancy Ectopic pregnancy Signs of haemoperitoneum No signs of haemoperitoneum Unstable Stable Surgical Medical Laparotomy Laparotomy or laparoscopy Laparoscopy Methotrexate 50mg/m2 im Salingectomy Salpingotomy

16 Laparoscopic pictures-ectopic Pregnancy

17 Adenexal mass Physiological cysts- Most common Ovarian benign tumours Ovarian cancers Tubo-ovarian abscess/endometrioma Fibroid Non-gynaecological-pelvic kidney!!!

18 Adenexal mass 21 yr old seen in A and E 4-5 days history of intermittent right lower-quadrant pain, nausea and one episode of vomiting Discontinued pill 6 months ago and not currently sexually active BHCG negative. Afebrile, WBC 10,600 VE=7-8 cm slightly tender adenexal mass

19 Adenexal mass 1.What is the differential diagnosis 2.What should be the next step Observation US CT Laparoscopy Laparotomy

20 Adenexal mass Large ovarian tumour

21 Small physiological ovarian cyst in a hysterectomy specimen

22 Management of adenexal mass Important to have a pre-op diagnosis. Most not require surgery. Age, Ultrasound features, tumour markers most important in determining treatment. Serial/old ultrsound for comparison Premenopause 15% malignant, post-menopause 50% malignant

23 Adenexal mass/ovarian cyst 40 yr old presents with occasional right lower abdominal pain Pelvic examination suboptimal due to obesity. Pelvic US showed normal size uterus and a 4 cm right adenexal simple cyst but a thin septum. CA125 was 20 U/mL (range=0-35 U/mL). Next step:

24 Question -adenexal mass/ovarian cyst OCPX3 months followed by pelvic exam Trans-vaginal ultrasound in 3 months Colour doppler CT Laparoscopy