GYNECOLOGY

SGD 5 - CasE 2
POMADA, Kristia Anne
PON, Corazon
CASE PRESENTATION
A 40-year-old G6P3(3-0-3-3) came to the clinic for FP advice.
She is a known hypertensive but controlled with Losartan/Amlodipine 100/10
mg once a day. She had history of one ectopic pregnancy and two abortions on her
last 3 pregnancies. Her husband is a 46-year-old OFW who comes home every year.
She is a nonsmoker and nonalcoholic beverage drinker.

On PE, her BP was 140/90. Breast examination revealed a suspicious breast mass
on palpation. The rest of the findings were within normal. Her husband is expected to
arrive in 3 months time. How would you manage this patient?
PERTINENT FINDINGS
● 40-year-old G6P3 (3-0-3-3)
● 1 ectopic pregnancy and 2 abortions
● Hypertensive (BP was 140/90)
● Breast mass
CONTRACEPTIVE
METHODS
 Female Sterilization
Pros Cons

● Reduces risk of ovarian cancer following tubal ligation. ● Does not protect against STIs

● Older women are less likely to regret permanent

sterilization.

● A woman can rely on sterilization for contraception

immediately after laparoscopic and abdominal
approaches. No additional contraceptive protection is
needed to prevent pregnancy.

● Sterilization does not affect the sex drive or hormone

levels.
 Levonorgestrel-releasing intrauterine system
(Mirena)

Pros Cons

● Appropriate for hypertensive women
● Does not not interfere with sexual intercourse,
wearing tampons, or using other vaginal
medications
● Appropriate for women ages 40 and above
● Not advisable if you have abnormal vaginal bleeding, a
pelvic infection, certain other problems with your uterus or
cervix, or if you have breast or uterine cancer, liver
disease or liver tumor, or a weakened immune system.
 CONTRACEPTIVE METHODS
Copper intrauterine device
Pros
● does not contain hormones and therefore does not
affect frequency of bleeding.
● highly effective, with a 98-99 percent success rate
over five years of IUD use
● Fertility returns promptly on discontinuation
● Starts working right away
Cons
● Menorrhagia is a frequent complaint, as are
dysmenorrhea and polymenorrhea. These are the
major reasons for IUD discontinuation as well
● There is a higher risk of ectopic pregnancy if
conception occurs with an IUD in situ, though
pregnancies are very rare with this method
 Progestin-only contraceptives injectables
(depot medroxyprogesterone acetate)
Pros
● depot medroxyprogesterone acetate (DMPA;
Depo-Provera) does not significantly affect blood
pressure
● If used correctly, the contraceptive injection is more
than 99% effective
● useful for women who cannot use contraception that
contains estrogen
● Decreases risk for endometrial cancer
Cons
● associated with a reduction in bone mineral density
(BMD) in women of all ages
● It does not protect against sexually transmitted
infections (STIs), so you may need to use condoms
as well
● Side effects can include weight gain, headaches,
mood swings, breast tenderness and irregular
bleeding
● Progesterone- only pill- contraindicated in patients
with a history of ectopic pregnancy.
 Barrier Method

Pros Cons

● Prevents sexually transmitted infections ● Less effective

● Do not have the side effects of hormonal ● Contraindicated in people with latex allergy
contraceptives ● The patient and her partner may not like
● Obtained without a prescription and easily how condoms feel and may impact the
purchased over the counter at pharmacies. enjoyment of sex
Estrogen Containing Contraceptive
Pros
● Reduces heavy menstrual bleeding, bone
loss, vasomotor symptoms, and risk of
ovarian, endometrial and possibly
colorectal cancers.
● Benefit in preventing declines in bone
density that accompany late
perimenopause.
Cons
● Increases the risk of venous and arterial
thromboembolic events.
● Associated with a 20% increased risk of
breast cancer.
● Risks outweighs the benefits in women with
either controlled hypertension or elevated
blood pressure, and higher age.
 THERAPEUTIC
LIST OF PROBLEMS OBJECTIVES
1. Risk for miscarriage and 1. Manage her chronic hypertension
pre-eclampsia if patient gets and maintain normal levels
pregnant 2. Determine if the breast mass is
2. Suspicious breast mass benign or malignant
3. Chronic hypertension 3. Family planning
MANAGEMENT
Chronic hypertension
● Accompany antihypertensive medication with dietary modifications and physical
activity

Breast mass
● Consider breast ultrasound to determine if lump is solid or fluid-filled (cystic)
● If it is cystic, aspiration may be done. Follow-up clinical breast examination after 4
weeks
 PATIENT EDUCATION/ COUNSELING

I. Advice patient on the need to maintain her blood pressure within normal levels
- If the patient becomes pregnant in the future, uncontrolled bp could put her at risk for
pre-eclampsia
II. Family planning options
- Discuss the top-tier and second-tier contraceptive methods and which ones are suitable for
her current health status
III. Thoroughly counsel patient on the advantages and disadvantages of the different contraceptive
methods; clear any misconceptions the patient may have
IV. Keep the patient well-informed to alleviate anxiety
FOLLOW-UP

★ Patients should be advised to return at any time to discuss questions or concerns about
contraceptive method use, but for most women, routine follow-up visits are not required
★ assess for satisfaction and concerns, side effects, changes in health status or medication
use that might affect eligibility for continued use, and changes in blood pressure
★ Follow-up clinical breast examination
★ Check for signs of pelvic infections that would require immediate treatment
END