34 Malay G2P1 came with uterus larger than date for assessment with history of nose bleeding in early pregnancy, whitish discharge with foul smelling & streak of greenish mucus (forgot when); completed treatment of vaginal pessary for 3 days. Upon further questioning, she had cystectomy for endometriosis 9 years ago & 1 untried uterine scar for EMLSCS due to prolong labour.
So what to highlight in history?
Causes of larger than date such as wrong date, fetus causes (big baby, multiple gestation), polyhydramnios, pelvic mass (uterus/ovarian mass)
Whitish discharge with foul smelling & streak of greenish mucus..what do likely cause?
At first, I thought it was bacterial vaginoses but it is actually candidiasis with superimposed infection because patient was treated using pessary for 3 days which most likely is Canesten pessary
Nose bleed common in pregnancy?
Yes for some because of generalised vasodilatation affecting Little's Area. (some may presented with gingivitis; also due to same causes)
Stages of endometriosis?
(anatomical staging) ---> not related to symptoms/fertility prognosis
stage 1 (minimal) - superficial lesion with filmy adhesions
stage 2 (mild) - as above plus some deep lesions in pouch of Douglas
stage 3 (moderate) - as above plus endometrioma in ovary & more adhesions
stage 4 (severe) - as above plus endometrioma with extensive adhesions
So in this patient at least stage 3
Ultrasound was done & found that normal fetus weight with normal AFI & no adnexal or uterine mass...so what happen?
Possibly of adhesion due to previous surgery that lead to upward stretching of the uterus lead to larger than date (based on SFH)
p/s: little bit sad because unable to clerk uv prolapse today because too many people have clerk it (hard-to-find admission!) and I've clerk 1 patient with PIH..after clerking the BP was 150/100 mmHg. I felt that I'm the one causing it...I did pray a lot hopefully patient did not develop pre-eclampsia/severe hypertensive crisis.
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