Pregnancy, Childbirth, & the Puerperium


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G10_F1.jpg"}},{"insert":"\n\n"},{"insert":"Wednesdays are the busiest at the free women\u0027s health clinic where you work.\r\n \r\nExhausted from your recent night shift, you remind yourself of how much you love working here. Treating women is a step towards empowering them, towards bringing change...\n\nYour wandering self-affirmation is interrupted by the receptionist announcing the arrival of your first patient.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G10_F2.jpg"}},{"insert":"\n\n"},{"insert":"Tina, a 41-year-old event coordinator in a busy PR firm, has come in to discuss a rather sensitive issue. You create an environment of comfort and confidence with practiced ease.\r\n\r\n\u0022My period has been a nightmare for the last few months, doctor. It\u0027s very heavy.\u0022\n\n\u0022I have to check myself every half-hour for the first couple of days, just to make sure I haven\u0027t soaked through my clothes. It\u0027s embarrassing.\u0022 Tina blushes, but appears relieved to share her worries with you.\r\n\r\n\u0022There\u0027s nothing to be embarrassed about, Tina, it\u0027s not in your control,\u0022 you sympathize.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G10_F3.jpg"}},{"insert":"\n\n"},{"insert":"On taking a detailed history, you discover that her period has previously been regular, although occasionally excessively heavy.\r\n \r\nNow, however, she is forced to spend the day in bed at least once a month. This has been adversely impacting her work and she fears she may lose her job.\n\nShe lives with her husband and two teenaged children.\r\n \r\nShe is a social drinker and has been smoking half a pack a day of cigarettes for the last 15 years.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G10_F4.jpg"}},{"insert":"\n\n"},{"insert":"Tina takes aspirin 325mg and metoclopramide 5mg for migraines related to stress at her workplace a few times a month. There is no further relevant medical history.\r\n \r\nHer mother, too, suffered from long and heavy periods and underwent a hysterectomy at age 40. She currently has osteoporosis. Her father died of a heart attack at 65.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G10_F5.jpg"}},{"insert":"\n\n"},{"insert":"Tina\u0027s records show that in the past she was on the pill for a few months. Due to poor adherence, she had to take emergency contraception a few times.\r\n \r\nShe then opted to insert a progestogen IUD, which led to irregular periods and intermenstrual spotting.\r\n \r\nShe found this distressing and asked for the device to be removed after three months.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G10_F3.jpg"}},{"insert":"\n\n"},{"insert":"Tina is currently on her period and has had to take the day off again. Her last pap smear, one year ago, was normal. There is no personal or family history of easy bruising or spontaneous bleeding.\r\n\r\n\u0022I\u0027m ready to go under the knife if need be, doctor,\u0022 she says, referring to her mother\u0027s treatment. \u0022It\u0027s not like I wish to have more children, so what\u0027s the point of dealing with all this?\u0022\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G10_F7.jpg"}},{"insert":"\n\n"},{"insert":"\u0022May I examine you, to see if we can find an underlying cause for the excessive bleeding?\u0022 you ask, and Tina agrees. You proceed to examine her systematically. \r\n \r\nHer vitals are stable. Apart from conjunctival pallor, the general and systemic examinations, including an abdominal exam, are within normal parameters.\n"}]}


{"ops":[{"insert":"On pelvic examination, you find the cervical os closed. There are no lesions, tenderness, or masses. The uterus is anteverted, round, and unenlarged.\r\n \r\nYou estimate a blood loss of around 30mL during the per speculum examination alone. A urine dipstick test is normal and a pregnancy test negative.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G10_F9.jpg"}},{"insert":"\n\n"},{"insert":"You order routine blood work and a pelvic ultrasound.\r\n \r\nA few days later, Tina comes in to discuss the results. She is anxious to find a cure as soon as possible.\r\n \r\nHer bloodwork reveals a hemoglobin of 10.8g\/dL (12.3-18.3), an MCV of 75fL (80-96), and an MCH of 26 pg (27-33). The remaining tests show no abnormalities.\n"}]}


{"ops":[{"insert":"The pelvic ultrasound shows an anteverted, enlarged, hyperechoic uterus. It measures 40mm along the AP diameter with a length of 75mm. The endometrium is smooth and regular, with a thickness of 5mm. Both ovaries are visualized and appear normal. There is no fluid in the pouch of Douglas.\n"}]}