This document presents 5 case studies of common gynecological problems: 1. A pregnant woman at 7 weeks with severe vomiting was found to have hyperthyroidism and twins. She was treated and her pregnancy continued. 2. A woman with recurrent vaginal infections was prescribed long-term antifungal medication. 3. A woman with chronic pelvic pain was found to have adenomyosis after diagnostic tests and surgery. 4. A woman with heavy periods and fibroids underwent a myomectomy and later became pregnant. 5. A postmenopausal woman was found to have endometrial cancer after continued bleeding and tests, and was treated with surgery and radiation.

1. Case-study of Common
Gynaecological Problems
By
El-Said Abdel-Hady,
MSc, PhD, MRCOG,
Mansoura University.

2. Case-study
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1-Vomiting during pregnancy.
2-Recurrent vaginal moniliasis.
3-Chronic pelvic pain.
4-Menorrhagia.
5-Postmenopausal bleeding.

3. Case No 1
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Primigravida, pregnant 7 weeks,
presented with severe persistent vomiting.
USS revealed twin gestational sacs.
Pulse 120 beat/min.
B.P 90/60 mmHg.
Temp. 37.6 degree Celsius.
Body weight 55 Kg.

4. Case No 1
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What would be your management?

5. Case No 1
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She was admitted to the Gynae ward and
received IV fluid therapy, anti-emetics and
antacids.
FBC, urine analysis, LFT and KFT and
electrolytes were normal apart from mild
hyponatraemia (Na 128 mm/l).

6. Case No 1
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Initial improvement for few days, then relapse of
persistent vomiting associated with hematemesis,
severe hyperacidity and a tinge of jaundice.
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Body weight was 51 kg.
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What to do next?

7. Case No 1
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She was referred to GIT consultant and Upper
GI endoscopy revealed gastritis.
Naso-gastric feeding and IV antacids were given.
Further investigations for liver enzymes, thyroid
function tests, urea & electrolytes and level 3
abdominal and obstetric ultrasound were
ordered.

8. Case No 1
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TFT revealed hyperthyroidism, and antithyroid medication was started.
Obstetric ultrasound revealed viable twin
pregnancy with CRL 8 weeks.
Hyperkalaemia and hyponatremia were
corrected.

9. Case No 1
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There was no significant improvement over
the next few days and patient and family
have requested termination of pregnancy.
How to council?

10. Case No 1
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The patient was transferred to the high
dependency unit for proper fluid and
electrolyte monitoring.
Discussions regarding selective fetal
reduction versus termination of pregnancy
continued.

11. Case No 1
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Gradual improvement was observed while on the
HDU, body weight increased and the nasogastric tube was removed.
She continued her medication for few days and
then was returned to the ward.
How to plan your management for the rest of
pregnancy?

12. 2-Recurrent vaginal moniliasis
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35 years-old para 3, using IUCD for
contraception.
Complaining of white curdy vaginal
discharge and vulval itching for 2 weeks.
She has had similar episodes over the last
2 years.

13. 2-Recurrent vaginal moniliasis
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What would be your initial
management?

14. 2-Recurrent vaginal moniliasis
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The IUCD was removed and a 3 night course
of antifungal cream/pessary was prescribed.
She experienced relief of symptoms for few
days, then,
She developed recurrence of intense itching
and discharge.

15. 2-Recurrent vaginal moniliasis
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What to do next?

16. 2-Recurrent vaginal moniliasis
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Systemic antifungal was prescribed, to
be repeated one course every month
(just before menstruation) for 6 months.

17. 3- Chronic pelvic pain
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A 43 years old, para 4 presented to
your clinic with chronic pelvic pain for 6
months.
There was congestive dysmenorrhea
but no dyspareunea.
Gynaecological examination was
entirely free and pelvic USS was
normal.

18. 3- Chronic pelvic pain
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How to manage?

19. 3- Chronic pelvic pain
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She was referred to GIT, urology and
orthopedic consultants and no cause
was identified.
Diagnostic laparoscopy was also
normal.
How to proceed?

20. 3- Chronic pelvic pain
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GnRH was prescribed for 3 months and
she experienced some relief of pain.
What to do next?

21. 3- Chronic pelvic pain
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TAH & BSO was done and
histopathology revealed adenomyosis.

22. 4- Menorrhagia
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A 33 years-old para 0+0 presented with
menorrhagia.
Her periods are heavy and last for 10 days.
USS revealed multiple uterine fibroids the
largest was 5X4 cm.
Her Hb was 7 gm%.

23. 4- Menorrhagia
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What would by your management?

24. 4- Menorrhagia
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Blood transfusion(4units) and
haemostatics were given and her Hb
became 11 gm%.
She refused myomectomy as she was
trying for conception.

25. 4- Menorrhagia
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The next few periods were heavy and
her Hb became 8 gm% after few
months.
What to do next?

26. 4- Menorrhagia
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HSG revealed submucous myomas with
patent tubes.
Hysteroscopic resection of 2 submucus
myomas bulging inside the cavity were
carried out.
No improvement of symptoms was
noted over the next few cycles.

27. 4- Menorrhagia
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She was counseled and agreed for
myomectomy.
8 myomas were removed and her
periods became reasonable afterwards.
Pregnancy occurred 6 months from
myomectomy.

28. 5-Postmenopausal bleeding
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A-65 years old para o+o complaining of serosangneous vaginal discharge on and off for 2
months.
She is diabetic and hypertensive.
Her doctor reassured her that there was
nothing to worry about, and gave her
haemostatics and vaginal wash.

29. 5-Postmenopausal bleeding
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What is your feedback to the doctor’s
comment?

30. 5-Postmenopausal bleeding
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She continued to bleed on and off for another
2 months, and went to see another doctor,
who asked for USS.
The USS showed endometrial thickness of
11 mm but no focal lesion.
She was prescribed gestagens for 3 months.

31. 5-Postmenopausal bleeding
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What is your feedback to gestagen
therapy in this situation?

32. 5-Postmenopausal bleeding
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Bleeding continued while on gestagen
and she went to see a third doctor, who
performed EUA and D&C.
Histopathology revealed poorly
differentiated adenocarcinoma of the
endometrium.

33. 5-Postmenopausal bleeding
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TAH , BSO and vaginal cuff was done,
followed by postoperative radiotherapy.

34. Thank you.
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El-Said Abdel-Hady.