Salient features

Patient M.I., 30 year/old housewife, married, who seek consult due to amenorrhea foe almost 2 months
and was accompanied by hypogastric pain, nausea, vomiting and vaginal bleeding. She was tested positive for
pregnancy test. Her LNMP was August 15-20, 2019 and PNMP is July 16-21, 2019. With family history of
hypertension on both sides of the family. Menarche was at 12 years old which lasted 3-4 days with an interval
of 28-30 days, amounting to 3-4 moderately soaked pads per day. Her blood pressure was 90/60 mmHg, heart
rate is 80 bpm, respiratory rate of 19 com and afebrile (36°C). Upon speculum exam, it was noted that she has
violaceous cervix with whitish mucoid vaginal discharge. A close soft, long, closed Uterus enlarge to 8 to 10
weeks size was noted during internal examination, the rest of the physical examination was unremarkable
1. What are your considerations (Differential Diagnosis)
Malignant ovarian teratoma
Pregnancy
2. What are the important contributing points in her history and physical examination that help you
rule in/out your differential diagnosis?

a. Mature ovarian Teratoma

The patient present with menstrual irregularity, amenorrhea, with nausea and vomiting which are
symptoms characteristic for teratoma. Patients with teratoma can also give a positive pregnancy test thus
misdiagnosis of pregnancy. But the patient did not have pelvic pain, bleating frequent urination and heaviness in
her abdomen which are also present in patients with teratoma. An ultrasound should be done to confirm for this
diagnosis together with laparoscopy procedure. Benign teratomas are bilateral in 10% to 15% of cases.
Characteristically they are unilocular cysts containing hair and sebaceous material Sectioning reveals a thin wall
lined by an opaque, gray-white, wrinkled epidermis, frequently with protruding hair shafts. Within the wall, it is
common to find grossly evident tooth structures and areas of calcification. Microscopically, the cyst wall is
composed of stratified squamous epithelium with underlying sebaceous glands, hair shafts, and there skin
adnexal structures. In most cases tissues from other germ layers can be identified, such as cartilage, bone,
thyroid, and neural tissue. Dermoid cysts are sometimes incorporated within the wall of a mucinous
cystadenoma. About 1% of the dermoid undergo malignant transformation, most commonly to squamous
cell carcinoma, but also to other cancers as well (e.g., thyroid carcinoma, melanoma)

b. Pregnancy
The patient present with nausea and vomiting, cessation of menstruation for 2 months which are the initial
symptoms of the patient. Signs of pregnancy are also present, violaceous cervix due to increase blood supply
which is called Chadwick’s that can be present 6 weeks into pregnancy. Goodell’s sign or softening due to
edema of the cervix is also present, it is the softening of the cervix which are present 6-8 weeks of pregnancy.
Pregnancy test was also positive which could mean that the patient is pregnant.

What are the important contributing points In her history and physical examination that help you rule in and out
your differential diagnosis

A transvaginal ultrasound was done 7 days after the initial consult, she denies having vaginal bleeding and
hypogastric pain with very occasional nausea and vomiting episodes. The result of the transvaginal ultrasound
was a single, live, intrauterine pregnancy 8 weeks age of gestation, no sub chorionic hemorrhage and normal
ovaries.

3. What is your impression at this point? Give complete diagnosis?

EARLY SINGLE LIVE INTRAUTERINE PREGNANCY OF ABOUT 8 WEEKS 1/7
4. What laboratories and ancillary test will you request for this patient?
a. CBC with DC/PC
 Complete blood count should be requested to detect any anomalies of deficiency in blood cells. It is one
way to know if a pregnant patient is anemic or with dehydration. Differential count may also show if the
patient is currently have infection due to viral or bacterial etiology. Platelet count also is important for
the success of the pregnancy and detect problem with blood clotting.

b. Blood typing with Rh factor

 Blood typing is important to know if there is an blood incompatibility between the mother and the baby
specially with Rh incompatibility since it can lead to immune hydrops faetalis on the second pregnancy.
Blood type and Rh factor identification are also vital in requesting blood products in emergency cases
that needs blood transfusion.

c. Urinalysis
 Your urine may be tested for red blood cells (to see if you have urinary tract disease), white blood cells
(to see if you have a urinary tract infection), and glucose (high levels may be a sign of diabetes
mellitus). The amount of protein also is measured. The protein level early in pregnancy can be compared
with levels later in pregnancy. High protein levels in the urine may be a sign of preeclampsia, a serious
complication that usually occurs later in pregnancy or after the baby is born. This can also indicate
urinary tract infection that can move up the tract and cause pyelonephritic and might cause preterm labor
which puts the baby at high risk of serious complication and even death.
d. Fasting blood sugar and Oral Glucose tolerance test
 Fasting blood sugar can show you if your patient is diabetic or not. Pregnancy outcome can be expected
once a pregnant patient is diabetic. Oral glucose tolerance test on the other hand can be a
sign gestational diabetes. This test usually is done between 24 weeks and 28 weeks of pregnancy. If you
have risk factors for diabetes or had gestational diabetes in a previous pregnancy, screening may be done
in the first trimester of pregnancy.
e. HbsAg
 This test is done to know is the mother has Hepatitis B infection because this can be transferred to the
fetus. This can also be done with Hepatitis C screening.
f. Rubella IgG
 Rubella (sometimes called German measles) can cause birth defects if a woman is infected during
pregnancy. Your blood is tested to check whether you have had a past infection with rubella or if you
have been vaccinated against this disease. If you have not had rubella previously or if you have not been
vaccinated, you should avoid anyone who has the disease while you are pregnant because it is highly
contagious. If you have not had the vaccine, you should get it after the baby is born, even if you are
breastfeeding. You should not be vaccinated against rubella during pregnancy.
g. VDRL, RPR
 Syphilis can seriously complicate pregnancy and result in spontaneous abortion, stillbirth, non-immune
hydrops, intrauterine growth restriction, and perinatal death, as well as serious sequelae in liveborn
infected children. While appropriate treatment of pregnant women often prevents such complications,
the major deterrent has been inability to identify the infected women and get them to undergo treatment.
Screening in the first trimester with non-treponemal tests such as rapid plasma reagin (RPR) or venereal
disease research laboratory (VDRL) test combined with confirmation of reactive individuals with
treponemal tests such as the fluorescent treponemal antibody absorption (FTA-ABS) assay is a cost
effective strategy. Those at risk should be retested in the third trimester.
h. HIV screening test
  If a pregnant woman is infected with HIV, there is a chance she can pass the virus to her fetus. HIV
attacks cells of the body’s immune system and causes acquired immunodeficiency syndrome (AIDS). If
you are pregnant and infected with HIV, you can be given medication and take other steps that can
greatly reduce the risk of passing HIV during pregnancy, labor, or delivery.
i. Lipid Profile
 Both of the patients parents have a family history of hypertension, lipid profile should be done to know
if the patient has increase cholesterol and triglyceride that might cause hypertension during pregnancy
that may lead to Preeclampsia.

Patient came back one week after with normal laboratory result and without hypogastric pain and vaginal
spotting.

5. How do you advice the patient as to the frequency of her prenatal visits throughout the whole
pregnancy.
The frequency of prenatal check up depends on what age of gestation the pregnancy is currently in. If
<28 weeks a monthly check up is advised (during the first 2 trimester). If 28-36 weeks AOG check up of every
2 weeks is enough. If >36 weeks of AOG and close to term, every week check-up is advised.

6. What routine physical examination should be done each prenatal visit.

a. Fundal Height
 From the top of pubis symphysis to the top of fundus; between 20-34 weeks, fundus (in cm) correlates
closely with gestational age. At 12 weeks of AOG, the uterus becomes an abdominal organ. At 16 weeks
of AOG, the fundus is midway between the pubis symphysis and the umbilicus. At 20 weeks AOG, the
fundus should be at the level of the umbilicus.
b. Fetal Heart Tones
 Use a Doppler to hear the fetal heart sound as early as 8 weeks and almost 100% by 10 weeks. Use
stethoscope to hear the heart tones as early as 16 weeks, 80% at 20 weeks ans 100% at 22 weeks.
c. Leopold’s maneuver
 L1 or the fundal grip tells us what pole occupies the fundus, L2 is the umbilical grip which tells us
which side id the back, L3 is the Pawlick’s grip which indicate what fetal part lies above the pelvic inlet
and lastly the Pelvic grip, which tells us which side of the cephalic prominence.

7. What other routine ancillary or laboratories examination will you request for during the patient’s
prenatal care and at what weeks age of gestation should be done? (If the patient is classified to be low-
risk)
a. Glucose Tolerance test
 A screening test done at 26 to 28 weeks to determine the mother's risk of gestational diabetes. Based
on test results, your doctor may suggest a glucose tolerance test. Your doctor will tell you what to eat
a few days before the test. Then, you cannot eat or drink anything but sips of water for 14 hours
before the test. Your blood is drawn to test your "fasting blood glucose level." Then, you will
consume a sugary drink. Your blood will be tested every hour for three hours to see how well your
body processes sugar.
b. Ultrasound exam
 An ultrasound exam can be performed at any point during the pregnancy. Ultrasound exams are not
routine. But it is not uncommon for women to have a standard ultrasound exam between 18 and 20
weeks to look for signs of problems with the baby's organs and body systems and confirm the age of
the fetus and proper growth. It also might be able to tell the sex of your baby. Ultrasound exam is
also used as part of the first trimester screen and biophysical profile (BPP). Based on exam results,
your doctor may suggest other tests or other types of ultrasound to help detect a problem. Ultrasound
 uses sound waves to create a "picture" of your baby on a monitor. With a standard ultrasound, a gel
is spread on your abdomen. A special tool is moved over your abdomen, which allows your doctor
and you to view the baby on a monitor. The patient asked you during this consult about the necessity
of getting vaccines during the pregnancy. She claims that she had 2 previous doses of HPV vaccine.
The last was 3 months ago. She did not receive any other vaccines in the past.
 Urinalysis
A urine sample can look for signs of health problems, such as: Urinary tract infection, Preeclampsia
and diabetes. If your doctor suspects a problem, the sample might be sent to a lab for more in-depth
testing. You will collect a small sample of clean, midstream urine in a sterile plastic cup. Testing
strips that look for certain substances in your urine are dipped in the sample. The sample also can be
looked at under a microscope.

8. What are the vaccines given during pregnancy and give its dosing schedule?
a. Seasonal Influenza Vaccination
 Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant.
Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to
severe illness from influenza as well as hospitalizations and even death. Pregnant women with influenza
also have a greater chance for serious problems for their unborn babies, including premature labor and
delivery. Because vaccinating against influenza before the season begins is critical, and because
predicting exactly when the season will begin is impossible, routine influenza vaccination is
recommended for all women who are or will be pregnant (in any trimester) during influenza season,
which in the United States is usually early October through late March. Pregnant women should receive
inactivated influenza vaccine. Neither CDC nor ACOG recommend one type of flu vaccine. All
influenza vaccines available are recommended for use in pregnant women, with the exception of the live
intranasal vaccine, which is contraindicated for pregnant women.
b. Tdap Vaccination
 The overwhelming majority of morbidity and mortality attributable to pertussis (whooping cough)
infection occurs in infants who are less than or equal to 3 months of age, who are too young to begin
their own vaccine series against pertussis (whooping cough). Vaccinating pregnant women with Tdap
stimulates the development of maternal anti-pertussis antibodies, which pass through the placenta,
providing the newborn with protection against pertussis in early life, and protects the mother from
pertussis around the time of delivery, making her less likely to become infected and transmit pertussis to
her infant. The Advisory Committee on Immunization Practices guidelines recommend that health care
personnel administer a dose of Tdap during each pregnancy, irrespective of the patient’s prior history of
receiving Tdap. To maximize the maternal antibody response, passive antibody transfer and levels in the
newborn, optimal timing for Tdap administration is between 27 weeks and 36 weeks of gestation,
although Tdap may be given at any time during pregnancy. For women who previously have not
received Tdap, if Tdap was not administered during pregnancy it should be administered immediately
postpartum to the mother in order to reduce the risk of transmission to the newborn. It is also safe to
administer Tdap to breastfeeding women.

9. She asks you that she is schedule to receive her last dose of Cervical cancer vaccine 1 month from now.
What do you advise her about it?
The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not
cause problems for babies born to women who were vaccinated while pregnant, but more research is still
needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed. Wait
until the pregnancy is finished.

10.What are the vaccines contraindicated during pregnancy?

Live, attenuated virus vaccines, such as the MMR vaccine or the nasally delivered
influenza vaccine, are not recommended in pregnancy.