GYNECOLOGY WORKSHEET

Representative Case
This is a case of RA 32 yo, G0, married for 10 years, who came in for abdominal enlargement.
History of Present Illness
She has been having irregular menstruation for a year now, with scanty menstruation since 6 months
prior to consult. She reports weight loss and fatigue, (+) on and off tolerable hypogastric discomfort, (+)
non productive cough for about 3 months now. No vaginal spotting nor foul smelling vaginal discharges.

Medical History
LMP: June 20 minimal flow for 1 day
PMP: May 15- 1 day only
Self pregnancy test done: Negative
Family History:
Grandmother had heart problems and diabetes
Grandfather had history of lung problem

Physical Exam:
PE: stable vital signs with slightly pale palpebral conjunctiva
C/L: clear breath sounds
Abdomen: abdominal girth: 80 cm, slightly tense, NABS, no masses palpated, no tenderness, (+) fluid
wave test
BPE: cervix smooth, firm, no tenderness, uterus and adnexae cannot be assessed due to the tense
abdomen; minimal mucoid non foul discharges.

Overview of the Primary Working Impression
Pelvic Tuberculosis may be produced by either Mycobacterium tuberculosis or M. bovis. The primary site
for TB is usually the lungs. Early in the course of pulmonary infection the bacilli usually spread
hematogenously and the infection becomes located in the oviducts (subsequently in endometrium &
less commonly in ovaries). However, the oviducts are the primary and predominant site of pelvic
tuberculosis.
In general, pelvic TB may be insidious or rapidly progressive. The predominant presentations are
infertility and abnormal uterine bleeding. Mild to moderate chronic abdominal pain and pelvic pain
occur in 35% of women with the disease. Advanced cases are often accompanied by ascites. Some
women may be asymptomatic. Findings during pelvic exam are normal in 50% of cases. The remaining
SILLIMAN UNIVERSITY MEDICAL SCHOOL
SUBMITTED TO: Daphne Ravello Rana M.D DATE OF SUBMISSION: July 17, 2014
SUBMITTED BY:
Palomar, Christian A.
Pasuquin, Alvin G.
Reyes, Edessa Dane E.
Rodriguez, Arianne S.
Sibala, Jan M.
Gyne III
patients have mild adnexal tenderness and bilateral adnexal masses, with an inability to manipulate
adnexa because of scarring and fixation.

Types of Tuberculous Salpingitis
Exudative (wet) the tubes may be significantly enlarged. Although a large pyosalpinx may form, these
tubes show few adhesions and usually are reasonably mobile if surgery is needed. Frequently, the
organs contain a large amount of caseous material plus purulent exudates from secondary infection.
This is a relatively acute phase of the process.

Productive-Adhesive (dry) is found most frequently at laparoscopy or laparotomy, the tubes are
studded with tubercles and are densely adherent to the surrounding organs. The tubercles are seen
mostly near the attachment of the tube to the mesosalpinx. The wall is thickened and nodular, and the
fimbrae and tube are slightly swollen. Eventually when the process starts healing, it results in
calcification and fibrosis.

Primary Working Impression
We rule this in because the patient is a Filipino and she is in her reproductive age. Her chief complaint
was abdominal enlargement. Important clues in the history include her 10 years of married life without
offspring which may suggest that she is infertile, her1-year-irregular menstruation with scanty
menstruation 6 months prior to consult. She did notice weight loss, fatigue and did experience on and
off tolerable hypogastric discomfort and a non productive cough for about 3 months.
In the family history, her grandfather had history of lung problem, which we assumed was tuberculosis.
For the physical examination, patient was noted for slightly pale palpebral conjunctiva, abdominal girth
80 cm, slightly tense abdomen, (+) fluid wave test. All these information are highly suggestive of a
possible pelvic tuberculosis.
Symptomatology
Pulmonary Tuberculosis Pelvic Tuberculosis
Easy fatigability
Anorexia
Weight loss, body wasting
Persistent, long term low grade fever
Chills and night sweats
Persistent , progressive cough which may
be non productive at first but may
produce purulent sputum in the long
term
Dyspnea
Hempotysis
Anemia

Infertility most common initial symptom
(85% of cases)
Lower abdominal pain / pelvic pain
second most frequent complaint (25-50%)
Variety of menstrual problems 3rd most
common symptom (10-40%)
General Malaise associated with weight
loss, fatigue












Pathophysiology of Pelvic Tuberculosis
Schematic Diagram for Tuberculosis
















































Differential Diagnoses
MEIGS SYNDROME
Meigs syndrome is defined as the triad of benign ovarian tumor, ascites and pleural effusion. We
considered this because of the menstrual irregularity the patient is experiencing as well as the
abdominal bloating which would suggest the presence of ascites. Another point is the non productive
cough of the patient and known weight loss of the patient together with fatigability. In the physical
examination of the patient, there was an increase in the abdominal girth of the patient and a positive
fluid wave test which signifies the presence of ascites. However, the uterus and the adnexae were not
able to be palpated because of the tense abdomen which means that there could be the presence or the
absence of a mass. We ruled it out because there was clear breath sounds upon auscultation of the
lungs which would mean that there is no pleural effusion, there was no shortness of breath, the vital
signs are stable and there is abdominal pain.


OVARIAN CARCINOMA
Ovarian carcinoma is a malignancy in the ovaries. We considered this because of the presence of
abdominal pain experienced by the patient, the noticeable weight loss, the fatigability of the patient,
and the visible abdominal distention and bloating suggesting ascites. In the PE, the fluid wave test was
positive and the abdominal girth is increased signifying the presence of ascites. However, the uterus and
the adnexae was not able to be palpated because of the tense abdomen which means that there could
be the presence or the absence of a mass. We ruled this out because there was no vaginal bleeding
because the patient was oligomenorheic, there was no urinary symptoms or constipation or any
compressive signs due to an enlarging mass.






Diagnostic Procedures
In this case, routine laboratory studies are of little value. In Complete Blood Count (CBC) most
patients have a normal white blood cell count with differential, although there is a tendency to
lymphocytosis and anemia is sometimes seen. ESR may also be done to detect possible inflammation
and Routine Urinalysis to detect urinary tract infections and renal disorders. The microscopic
examination of urine of the patient may show hematuria or a bacteriuric pyuria if there is concomitant
urinary tract involvement.

Tuberculin Skin Test may also be done to demonstrate infection with Mycobacterium
tuberculosis although it is substantially less than 100% sensitive and specific. Pelvic X-ray is used to
detect any calcifications found in the pelvis but this is not routinely done anymore. Endometrial biopsy
and culture are the primary methods in diagnosing pelvic tuberculosis. These are done late in the
secretory phase of the cycle. The specimen for culture, although it will take time to obtain an isolate, is
placed in a special culture medium called Lowenstein Jensen medium specific for growing
Mycobacterium tuberculosis organisms while the other specimen is sent for histologic examination. The
histologic findings of classic giant cells, granulomas and caseous necrosis confirm the diagnosis. In some
cases pelvic tuberculosis may not be diagnosed until laparotomy or celiotomy, when the characteristic
changes may be visualized. The distal ends of the oviduct remain everted, producing a tobacco pouch
appearance.

Ancillary procedures:
To rule out Meigs Syndrome and Ovarian Cancer, CA-125 is ordered along with transabdominal/
transvaginal ultrasound. CA-125 is not a screening tool for ovarian cancer since it is not specific and it
can also be found elevated in other diseases like Meigs Syndrome, endometriosis, colon cancer and
during menstruation, but it can helpdetect early ovarian cancer in those at high risk of developing the
disease. Transabdominal or Transvaginal Ultrasonography can also be ordered to help investigate a
pelvic mass and confirm the presence of an ovarian mass and ascites, as well as adnexal masses
containing scattered small calcifications. However, the primary method for detecting Ovarian cancer is
by doing biopsy after the removal of the ovary.

List of Problems and Therapeutic Objectives
Treatment
This patient came in for abdominal enlargement, has been having irregular menstruation for a year now,
with scanty menstruation since 6 months PTA, infertility, on and off hypogastric discomfort and
accompanied with weight loss, fatigue and nonproductive cough for about 3 months now. Upon physical
exam, the patient has slightly pale palpebral conjunctiva, increased abdominal girth, with tense
abdomen and is found (+) fluid wave which indicates ascites.
The goals are directed toward the treatment of the underlying signs and symptoms manifested
by the patient, mainly the treatment of pelvic tuberculosis (wet type), to treat ascites, as well as the
signs and symptoms of pelvic TB mainly the anemia, fatigue, nonproductive cough, irregular
menstruation as well as to restore fertility.




Surgical Treatment
Pelvic tuberculosis is managed the same way as pulmonary TB. Patient is admitted for initiation of
therapy, observation, and ensurance of appropriate compliance. Initial therapy consists of 5 drugs
(isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin) because of the emergence of
MDR-T. MDR-TB is a resistance of the organism to 2 or more agents including isoniazid. This multidrug
regimen should be started until patients culture result yield specific sensitivity.
In case this patient is not responsive to the medical treatment mentioned above, surgical treatment
should be opted. Surgery is also done with the following indications: Women with persistent pelvic
masses, those with resistant organisms, older than 40, endometrial cultures remain positive.
Since this patient is only 32 years old. It is very likely that she will be responsive to medical therapy.
Success in medical therapy will result in treatment of her infertility and in effect she will become
pregnant thereafter.