OBGYN CASES FILE: DIFFERENTIAL DIAGNOSIS , PHYSIOLOGY, CLINICAL PRESENTATION, WORK UP AND TREATMENT OF OBGYN CASES

DIFFERENTIAL DIAGNOSIS , PHYSIOLOGY, CLINICAL PRESENTATION, WORK UP AND TREATMENT OF OBGYN CASES. • Case 1: Genuine Stress Incontinence: incontinence through the urethra due to sudden increase in intra-abdominal pressure, in the absence of bladder muscle spasm o Differential Diagnosis: ▪ Genuine stress incontinence: • No delay in incontinence with valsalva ▪ Urge Urinary Incontinence: requires urge or delay from a cough; due to uncontrollable detrusor muscle contraction • Delay incontinence with valsalva ▪ Overflow incontinence: associated with diabetes or neuropathy • Large post-void residual o Physiology: ▪ Normal: The pressure of the urethra and support from the pelvic diaphragm is greater than the bladder pressure providing continence. ▪ Normal: valsava “cough” intra-abdominal pressure is exerted on the bladder and the proximal urethra providing continence ▪ Adnormal: proximal urethra is outs the pelvic diaphragm. Valsalva increases intra-abdominal pressure on the bladder, but the proximal urethra causing incontinence o Clinical Presentation: ▪ Multiparous woman ▪ Incontinence related to stress activities ▪ No urge component and no delay from valsalva to drip o Workup: ▪ H and P, UA, and Post-void residual ▪ GSI: 1) timed void and keigel exercises 2)urethropexy ▪ UUI: anticholinergic to prevent detrusor muscle contraction ▪ OI: catheter o Treatment: ▪ Urethropexy: movement of the proximal urethra back into the pelvic diaphragm ▪ Midurethral slings: mesh that is attached to act as a hammoack for the proximal urethra • Transvaginal or transobturator • Case 2: Health Maintenance o Health maintenance approach ▪ Cancer screening, immunizations, addressing common diseases o Primary Prevention: modifying risk factors o Secondary Prevention: catches disease in the asymptomatic stage o Table 2-1, page 34 o Clinical Pearls: ▪ Most common COD in women 20 yo is MVA ▪ Most common COD in women ≥ 49 CVD ▪ Major conditions in the ≥ 65 age group • Osteoporosis, CVD, breast cancer and depression • Case 3: Uterine Inversion o Differential Diagnosis: ▪ Uterine inversion: ragged red mass ▪ Vaginal or cervical prolapse: smooth appearance o Clinical Presentation: ▪ Third stage of labor: • Placenta cord has lengthened, • A small amount of blood from the vagina • Placenta with a ragged reddish mass around it ▪ Due to traction of the umbilical cord without separation o Treatment: ▪ Anesthesiologist: • Possible emergency surgery • Halothane: relaxes uterus ▪ Cupped glove technique to reposition the uterus ▪ Start two IV lines ▪ Relax uterus • Halothane, terbutaline, magnesium sulfate ▪ After repositioning of the uterus give oxytocin o Clinical Pearls: ▪ Four signs of placenta separation • Gush of blood • Umbilical cord lengthening • Globular and firm shape of the uterus • Uterus rises to the anterior abdominal wall ▪ Almost certain to have maternal hemorrhage ▪ The fundus is the most likely site for placenta implantation leading to uterine inversion ▪ Abnormally retained uterus: labor stage 3 lasting greater than 30 minutes - next step: manual extraction ▪ Placenta accreta: increase risk for intrauterine inversion • Case 4: Perimenopause (Climacteric) o Clinical Presentation: ▪ Irregular menses (anovulatory cycles) ▪ Feelings of inadequacy (vasomotor symptom) ▪ Hot Flushes (hypoestrogenism) ▪ Pathologic fractures (hypoestrogenism osteoporosis) - thoracic spine is the most common area ▪ Vaginal atrophy (decrease epithelial thickness) o Workup: ▪ FSH and LH levels: abnormally elevated because of no feedback inhibition ▪ DEXA scan: BMD ▪ Hypothyroidism, diabetes mellitus, HTN, and breast cancer o Treatment: ▪ Estrogen therapy: • Advantages: decreases fracture incidence and lower incidence of colon and ovarian cancer; decreases incidence of hot flashses; with progestin lowers incidence of endometrial cancer • Disadvantages: continuous therapy -increases likelihood of CVS and breast cancer • Short term, low dose • NOTE: FSH feedback is regulated by inhibin not estrogen… so FSH would still be elevated with estrogen therapy ▪ Clonidine: antihypertensive that may be used to decrease hot flashes ▪ Raloxifene: • Selective estrogen receptor modulator • Prevents bone loss, but does NOT treat hot flashes