Dr. Punit Bhojani

Question 1 : A 45 year old woman who had two normal pregnancies 15 and 18 years ago presents with the complaint amenorrhea for 7 months. She expresses the desire to become pregnant again. After exclusion of pregnancy, which of the following is the next best test indicated in the evaluation of this patient's amenorrhea?

1. LH and FSH levels
2. Endometrial biopsy
3. Karyotyping
4. HSG

Question 2 : Which of the following is not an indication for Antiphospholipid antibody testing?

1. Three or more consecutive first trimester pregnancy losses
2. Unexplained cerebrovascular accidents
3. Early onset severe pre-eclampsia
4. Gestational Diabetes

Question 3 :  An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30 year old gravida 5, para 4 woman with an lUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the lUD is noted to be protruding from the cervical os. The most appropriate course of action is :-

1. Leave the lUD in place without any other treatment
2. Remove the lUD  to decrease the risk of malformations
3. Remove the lUD  to decrease the risk of infection
4. Terminate the pregnancy because of the high risk of malformations

Answer 1

Solution - (1)

This patient has secondary amenorrhea which rules out abnormalities associated with primary amenorrhea such as chromosomal abnormalities and congenital Mullerian abnormalities. The most common reason for amenorrhea in a woman of reproductive age is pregnancy, which should be evaluated first. Other possibilities include chronic endometritis or scaring of the endometrium (Asherman syndrome), hypothyroidism, and ovarian failure. The latter is the most likely diagnosis in a woman at this age. In addition, emotional stress, extreme weight loss, and adrenal cortisol insufficiency can bring about secondary amenorrhea. A hysterosalpingogram is part of an infertility workup that may demonstrate Asherman syndrome, but it is not indicated until premature ovarian failure has been excluded. Persistently elevated gonadotropin levels (especially when accompanied by low serum estradiol levels) are diagnostic of ovarian failure.

(Ref. Speroff, 7 th Edition, Pg. 444-448, 651-656)

Answer 2

Solution - (4)

Antiphospholipid antibodies including lupus anticoagulant (LA) and anticardiolipin antibodies.

aPTT nd a diluted russel viper venom test are done to identify LA (both are prolonged)

The antiphospholipid antibody syndrome is characterized by recurrent arterial and / or venous thrombosis, thrombocyopenia and fetal loss - especially still births, during the second half of pregnancy.

Pathological changes seen are placental vascular atherosis, intervillous thrombosis and decidual vasculopathy with fibrinoid necrosis leading  to inadequate  blood supply to fetus

Indications to identify Lupus Anticoagulant and ACL :

1. Recurrent pregnancy loss (first trimester abortions)
2. Unexplained second - or third - trimester loss
3. Early - onset severe preeclampsia
4. Venous or arterial thrombosis
5. Unexplained fetal growth restriction
6. Autoimmune or connective - tissue disease
7. False - positive serological test for syphilis 

(Ref. Williams Obstetrics, 22)

Answer 3  

Solution - (3)

Although there is an increased risk of spontaneous abortion, and a small risk of infection, an intrauterine pregnancy can occur and continue successfully to term with an lUD in place. However, if the patient wishes to keep the pregnancy and if the string is visible, the lUD should be removed in an attempt to reduce the risk of infection, abortion, or both. An IUD insitu does not cause any malformations/anomalies in the fetus. W.H.O recommends that if the IUD can be removed easily it should be removed to reduce the risk of infection and abortion If the IUD cannot be removed easily, it can be kept insitu and it will be expelled after placental delivery

Smart Study Series in Obstetrics & Gynecology by Dr Punit S Bhojani. An Elsevier publication

Uploaded in April 2010

Dr. Punit Bhojani

Q. 1) A 9 year old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at age 7 and adrenarche at age 8. The most common cause of this condition is:

1. Idiopathic
2. Gonadal tumors
3. McCune-Albright syndrome
4. Hypothyroidism

Q. 2) Emergency contraception prevents pregnancy by all of the following mechanisms, EXCEPT :

1. Delaying/inhibiting ovulation
2. inhibiting fertilization
3. Preventing implantation of the fertilized egg
4. Interrupting an early pregnancy

Q. 3) A 24 year old woman presents with new onset right lower quadrant pain and you palpate an enlarged, tender right adnexa. Which of the following sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle?

1. Lack of ascites
2. Unilocularity
3. Papillary vegetation
4. Diameter of 8 cm
   
   Ans. 1) - (1)
   Pubertal changes before the age of 8 years in girls and 9 years in boys are regarded as precocious. Although the most common type of precocious puberty in girls is idiopathic, it is essential to ensure close long-term follow up of these patients to ascertain that there is no serious underlying pathology, such as tumors of the central nervous system or ovary. Only 1 to 2% patients with precious puberty have an estrogen producing ovarian tumor as the causative factor. McCune Albright syndrome is also relatively rare and consists of fibrous dysplasia and cystic degeneration of the long bones, sexual precocity, and cafe au lait spots on the skin. Hypothyroidism is a cause of precocious puberty in some children, making thyroid function tests mandatory in these cases. Tumors of the central nervous system as a cause of precious puberty occur more commonly in boys than in girls; they are seen in about 11% of girls with precious puberty. (Ref. Speroff, 7th Edition, Pg. 392-400)
   
   Ans. 2) - (4)
   Emergency contraception is used to prevent pregnancy after the act of an unprotected intercourse. It is an interceptive. Its main action is to make the endometrium unsuitable for implantation. It may also prevent or delay ovulation and prevent fertilization of the egg by the sperms . It has however no role in the interruption of early pregnancy once conceived. They are not abortifacients or contagestives. They cannot interrupt an early pregnancy and hence a pregnancy test is recommended if the woman does not bleed within 7 days of the usage.
   
   Ans. 3) - (3)
   Approximately 20% of ovarian neoplasms are considered malignant on pathologic examination. However, all must be considered as placing the patient at risk. Given that most ovarian tumors are not found until significant spread has occurred, it is not unreasonable to attempt to operate on such patients as soon as there is a suspicion of tumor. Papillary vegetation, size greater than 8 cm, ascites, possible torsion, or solid lesions within the cysts are automatic indications for exploratory laparotomy. In a younger woman a simple unilocular cyst can be a follicular cyst which would regress after onset of the next menstrual period. If regression does not occur, then surgery is appropriate. Doppler ultrasound imaging allows visualization of arterial and venous flow patterns superimposed on the image of the structure being examined.

Smart Study Series in Obstetrics & Gynecology by Dr Punit S Bhojani. An Elsevier publication

Uploaded in June 2010