Residents Stump Profs

American College of Obstetricians and Gynecologists (ACOG) Junior Fellows stumped the Professors at ACM's 5th Scientific Session. ACOG's annual brainteaser that pits senior residents against a panel of professors left the profs guessing on three of four test cases.

The Prof Panel on stage, (l to r) Mary D'Alton, MD, FACOG;
AlanGarely, MD, FACOG; Beth Karlan, MD, FACOG;
Valerie Montgomery Rice, MD, FACOG.

"This was one of the best panels we've had in years and one of the most difficult sets of cases," said moderator and ACOG Fellow Russell Snyder, Col, MCU, USAF, from the University of Texas Medical Branch in Galveston, TX. "Our Junior Fellows have done a tremendous job preparing and presenting their cases."

The Professors included Mary D'Alton, MD, FACOG, from New York Presbyterian Hospital; Alan Garely, MD, FACOG from Winthrop University Hospital in Mineola, NY; Beth Karlan, MD, FACOG, from Cedars-Sinai Medical Center in Los Angeles; and Valerie Montgomery Rice, MD, FACOG, from Meharry Medical College in Nashville, TN.

The group successfully worked through the case of the Mysterious Mass, presented by District I representative Aimee Eyvazzadeh, MD, a 4th-year resident from Brookline, MA. The patient presented with a reddish purple mass at the introitus and in such pain that no vaginal or rectal exam could be performed. The mass seemingly appeared out of nowhere while the woman was on vacation.

The patient underwent pelvic ultrasound, which showed a swelling near the urethral orifice and a vascular mass between the vagina and urethra. An MRI showed abnormal contours on the right kidney, enlargement of the right ureter, and a mass in the urethra.

A pelvic exam was performed after a spinal block, revealing a 3-cm necrotic mass in the vagina. Cystocopy showed bilateral urethral orifices and a mass on the urethra. The problem, the panel correctly concluded, was a prolapsed ectopic ureter on the right side.

Lori Cashbaugh, MD, a 4th-year resident from District IV in Atlanta, managed to stump the panel. Dr. Cashbaugh presented a pregnant Vietnamese woman admitted for labor following membrane rupture. She gave birth to a 3200-g male after 7 1/2 hours of labor, then began bleeding profusely from the vagina. She was given aggressive IV fluid treatment for hypotension and tachycardia and vaginal packing for the bleeding, then transferred to the obstetric ICU.

A few hours later, she began to complain of pain and numbness in the first three fingers of her right hand. The hand swelled to three times normal size and became extremely sensitive to touch or motion.

An hour or so later, the woman began to experience similar pain in the fingertips of her left hand. The skin and fingernail color remained normal on both hands, but the thumbs were adducted and the hand flexed at the wrist.

The problem? Acute carpal tunnel syndrome (CTS), Dr. Cashbaugh revealed. CTS occurs in 2% to 25% of pregnancies, typically secondary to fluid retention. It resolves spontaneously after birth.

"What is unusual here is CTS presenting postpartum," she explained. "We assume it was secondary to the aggressive fluid therapy. The problem was completely resolved with bilateral carpal tunnel release."

Kathleen Cooke, MD, a District IV resident from Charlotte, NC, offered a woman 36 weeks into pregnancy who presented with severe abdominal pain and hypothermia. She was pale and diaphoretic, but was rousable and was able to give a complete history. She had felt her fetus move the evening before, but remembered no movement since the onset of pain.

On exam, her cervix appeared long, thick, and closed, with no vaginal bleeding. There was blood in her urine, which resolved within 2 hours. Her creatinine level was elevated, but all other lab values were within normal limits. There was no detectable fetal heartbeat.

The panel's working diagnosis was an abruption, followed by intrauterine fetal death. Dr. Cooke agreed, but pointed out that there were no known risk factors for abruption and no apparent cause for elevated creatinine.

The decision was made to induce labor, but the patient was unresponsive to IV pitocin. Ultrasound revealed a 9-cm clot and the fetus in a transverse position within the uterus.

The patient was taken to the OR for exploratory laparatomy and a possible hysterectomy. During the procedure, the uterus appeared pale and apparently rotated about 90o. It was eventually found that the uterus was rotated 270o. The final diagnosis: uterine torsion, which caused an amniotic embolism and fetal death. The woman was discharged on day 8 after a vertical hysterectomy.

Terry White, MD, a former resident from District IX in Philadelphia, offered the case of a 30-year-old Mexican woman who presented with severe abdominal pain that had persisted for about a week. There was no vaginal discharge, but her temperature was 102°, pulse 96, and white blood cell (WBC) count above 22,000.

Her distress was diffuse but there was no acute abdomen. The patient reported that an IUD had been inserted 5 years ago, although no IUD string could be found on examination.

Ultrasound revealed a right-side mass, 6 cm in diameter, and an image consistent with an IUD. Both were consistent with pelvic inflammatory disease with abscess, so the patient was started on antibiotic therapy, cultured for STDs, and the IUD removed with alligator forceps.

The IUD appeared to be a fragment, not a complete device. The patient's WBC count continued to climb and she was still in severe pain, with no pain or problem associated with bowel movements.

A colpotomy was performed and about 100 mL of purulent fluid was drained from the abscess. Specimens were sent to pathology for evaluation.

Symptoms improved rapidly after the procedure, but the pathology was confusing. What appeared to be part of an IUD was actually a piece of bone, possibly retained after a late-stage abortion or a piece of animal bone inserted for contraception. Gram-positive filaments were also found and identified as actinomyces.

The next step was to talk with the patient. She finally admitted to a pregnancy about 10 years earlier that had been terminated at about 4 months, the apparent source of the bone.

And the IUD? It never existed. The woman had assumed that an IUD had been inserted during a clinic visit several years earlier. Since she had not become pregnant, it was obviously effective, so she had been telling physicians that she had an IUD.

The final diagnosis was pelvic actinomycosis and secondary infertility caused by a fragment of fetal bone.