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I now have enough information to provide a thorough answer for all 3 cases. Let me compile the comprehensive response.

Clinical Case Discussion - Gynecology Cases (Sem. 6, Batch-53 C, Manipal University College Malaysia)

CCD FILE - Case 1: Ms. J.K., 28 years old

Case Summary

Differential Diagnosis

Most Likely: Uterine Fibroids (Leiomyoma)

The clinical picture strongly points to multiple uterine fibroids - the irregular, firm, uterine-origin mass with menorrhagia and primary infertility in a reproductive-age woman is classic. As noted in S Das Manual on Clinical Surgery: "Menorrhagia of some standing may be due to fibroid in women above 30 years of age but before menopause with irregular enlargement of the uterus (except in the submucous type in which the swelling will be smooth)."

Diagnosis	Supporting Features	Against
Uterine fibroid (most likely)	Irregular firm mass, menorrhagia, infertility, firm, hypogastric location	-
Pregnancy (gravid uterus)	Uterine mass, amenorrhea possible	She has regular periods; no amenorrhoea mentioned
Adenomyosis	Menorrhagia, enlarged uterus	Usually smooth/uniformly enlarged, not irregular
Ovarian mass / fibroma	Pelvic mass	Ovarian mass tends to be separate from uterus, cystic
Chronic PID / tubo-ovarian mass	Young woman, infertility	No fever/tenderness mentioned
Endometrial carcinoma	Uterine mass, bleeding	Very rare at 28; usually postmenopausal

Fibroid types to consider: Multiple intramural and subserosal fibroids account for the large, irregular mass; a submucosal component is likely causing heavy bleeding.

Management of Case 1

Immediate/Initial:

Correct anaemia: Check FBC, serum iron/ferritin; start oral/IV iron; consider blood transfusion if Hb critical (tachycardia + hypotension suggests significant anaemia)
Confirm uterine origin: Catheterize bladder first before palpation (S Das)
Urine pregnancy test to rule out pregnancy

Investigations:

Ultrasound pelvis (TVS/TAS) - first-line: maps number, size, location of fibroids; rules out ovarian pathology
FBC, coagulation profile (rule out coagulopathy as AUB-C)
Serum CA-125 (if ovarian mass not excluded)
MRI pelvis - gold standard for pre-surgical fibroid mapping (Grainger & Allison)
Hysteroscopy - assess submucosal component
Thyroid function, prolactin (rule out AUB-O/hormonal causes)

Medical Management (if fertility desired):

GnRH analogues (e.g., leuprolide): shrink fibroid volume by 30-50% pre-operatively; correct anaemia
Tranexamic acid / NSAIDs - reduce heavy bleeding temporarily
Combined OCP / LNG-IUS - heavy bleeding control (if submucosal excluded)

Surgical Management (given large fibroid + infertility):

Myomectomy - treatment of choice when fertility preservation is required; can be open, laparoscopic or hysteroscopic depending on fibroid location
Uterine artery embolisation (UAE) - alternative if surgery declined, though fertility outcomes less predictable
Hysterectomy is NOT appropriate here (28 years old, desires fertility)

For infertility: After myomectomy, evaluate tubal patency (HSG), ovulation, semen analysis for complete infertility workup.

CCD FILE - Case 2: Mrs. E., 45 years old

Case Summary

Clinical Diagnosis

Ovarian Malignancy (Ovarian Cancer) - until proven otherwise

The critical distinguishing features here:

All borders palpable (unlike fibroid uterus where lower border is not reachable)
Partly cystic, partly solid - classic for ovarian malignancy
Fluid thrill + flank dullness = ascites (not ovarian cyst, which causes central dullness and flank resonance - as S Das explains: ovarian tumour causes "dullness over the front of the abdomen with resonant areas in the flanks, whereas in ascites there is dullness on the flanks with resonance over the front of the abdomen")
First-degree family history of ovarian cancer - major risk factor
Indigestion/dyspepsia = common GI presentation of ovarian cancer

Note: The percussion finding here (resonant centre, dull flanks) is actually consistent with ascites - which is a sinister sign pointing to ovarian malignancy with peritoneal spread.

Differential Diagnosis

Diagnosis	Supporting Features	Against
Ovarian carcinoma (most likely)	Partly solid+cystic, ascites, family Hx, all borders palpable, age 45	-
Ovarian borderline tumour	Similar presentation, younger age	Less aggressive
Benign ovarian cyst (dermoid, endometrioma)	Cystic pelvic mass	No solid component in benign; no ascites
Tubo-ovarian abscess	Adnexal mass	No fever, no pain, no PID history
Uterine fibroid	Firm pelvic mass	Lower border reachable, partly cystic; ascites unlikely with fibroid
Pseudomyxoma peritonei	Ascites + mass	Rare; usually mucinous ovarian primary
Colorectal/GI malignancy with metastasis	GI symptoms	No weight loss; primarily ovarian features

Management of Case 2

Investigations:

Transvaginal/transabdominal ultrasound - first line; characterize mass (solid vs. cystic, septations, papillary projections, vascularity)
Serum CA-125 - elevated in ~80% of epithelial ovarian cancers; also check HE4 (more specific)
CT abdomen + pelvis with contrast - staging; assess peritoneal implants, LN involvement, omental deposits
MRI pelvis - better soft tissue characterization
CXR - pleural effusion (Meigs' syndrome or malignancy)
FBC, LFTs, renal function (pre-operative workup)
Ascitic fluid tap - cytology; LDH, protein
BRCA1/BRCA2 genetic testing given family history
CEA, CA19-9, AFP, LDH (germ cell / sex-cord stromal tumours)

Definitive Management:

Refer urgently to Gynae-Oncology MDT
Surgical staging and debulking (cytoreductive surgery): total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + pelvic/para-aortic lymph node dissection
Platinum-based chemotherapy (carboplatin + paclitaxel) - adjuvant or neoadjuvant
If BRCA mutation confirmed - PARP inhibitor (e.g., olaparib) as maintenance therapy
Counselling regarding prognosis, genetic counselling for first-degree relatives

PBL FILE - Case 1 (Mrs. M, 45 years old): Abnormal Uterine Bleeding

Case Summary

Clinical Diagnosis

Abnormal Uterine Bleeding (AUB) - likely AUB-O (Anovulatory) ± AUB-L (Leiomyoma/Adenomyosis)

At 45 years (perimenopausal), anovulatory cycles are the most common cause of AUB (Berek & Novak). The PALM-COEIN classification applies: the bulky uterus suggests possible adenomyosis (AUB-A) or leiomyoma (AUB-L).

PALM-COEIN Classification Applied:

P - Polyp (endometrial/cervical)
A - Adenomyosis (bulky uterus, no discrete mass - very likely here)
L - Leiomyoma (no palpable mass but could be small intramural)
M - Malignancy/hyperplasia (must exclude at age 45)
C - Coagulopathy (rule out)
O - Ovulatory dysfunction (perimenopause - most likely)
E - Endometrial (endometritis)
I - Iatrogenic
N - Not yet classified

Management

Investigations:

Urine/serum pregnancy test (exclude pregnancy first)
FBC - assess degree of anaemia
Thyroid function tests (TFTs) - hypothyroidism causes menorrhagia
Coagulation screen (PT, aPTT, platelets) - rule out AUB-C
Pelvic ultrasound (TVS) - assess endometrial thickness, adenomyosis features, fibroids
Endometrial biopsy / sampling (MANDATORY at age 45 to exclude endometrial hyperplasia/carcinoma - AUB-M)
Hysteroscopy - if sampling inconclusive; visualize polyps/submucosal fibroids

Medical Treatment:

LNG-IUS (Mirena) - first-line for heavy menstrual bleeding with bulky uterus; also treats adenomyosis
Combined OCP or progestogens - regulate cycles; treat anovulatory AUB
Tranexamic acid - antifibrinolytic; reduces blood loss by ~40%
NSAIDs (mefenamic acid) - reduce prostaglandin-mediated heavy bleeding
Iron supplementation for anaemia

Surgical Treatment (if medical fails):

Endometrial ablation - if no desire for future fertility; treats heavy bleeding
Hysterectomy - definitive treatment when other measures fail; consider at perimenopausal age with completed family

PBL FILE - Case 2 (Mrs. AH, 29 years old): Acute Pain Abdomen - Ectopic Pregnancy

Case Summary

Diagnosis with Justification: Ruptured/Leaking Right Tubal Ectopic Pregnancy

Justification:

Feature	Clinical Significance
6 weeks amenorrhoea	Confirms pregnancy
Right iliac fossa pain (crampy, 7/10)	Tubal distension / rupture on right side
Vaginal spotting	Decidual shedding as ectopic fails
HR 90, low volume + BP 100/60	Haemodynamic compromise from internal bleeding
Fainting on standing (orthostatic syncope)	Significant haemoperitoneum - surgical emergency
Prior surgical uterine evacuation	Instrumentation risk factor (endometrial scarring/adhesions)
3 years infertility	Suggests possible tubal pathology pre-existing

As stated in Berek & Novak's Gynecology: "The classic symptom triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding. This symptom group is present in about 50% of patients and is more typical in patients with a ruptured ectopic pregnancy." The haemodynamic instability here (low-volume pulse, hypotension, syncope) indicates likely rupture with haemoperitoneum.

Differential Diagnosis

Diagnosis	Supporting	Against
Ruptured ectopic pregnancy (most likely)	Amenorrhoea, RIF pain, spotting, haemodynamic instability, syncope	-
Ruptured corpus luteum cyst	RIF pain, haemoperitoneum possible	No amenorrhoea pattern; urine βhCG negative
Acute appendicitis	RIF pain	No amenorrhoea; no fever/anorexia; spotting not explained
Miscarriage (incomplete/threatened)	Amenorrhoea, cramping, spotting	Intrauterine; no haemodynamic shock usually
PID / Tubo-ovarian abscess	RIF pain	Fever expected; no amenorrhoea
Ovarian torsion	Severe pelvic pain	Sudden onset; less associated with amenorrhoea & spotting

How to Confirm Diagnosis

Serum βhCG - will be positive; serial levels help if stable (in ruptured, this is confirmatory not diagnostic as surgery is urgent)
Transvaginal ultrasound (TVS) - most important non-invasive test: look for empty uterus + adnexal mass + free fluid in pouch of Douglas; "no intrauterine pregnancy with free fluid + positive βhCG = ectopic until proven otherwise"
FBC - falling Hb/Hct confirms haemorrhage
Blood group + crossmatch - preparation for surgery
Diagnostic laparoscopy - both confirmatory AND therapeutic (gold standard)
Culdocentesis (if ultrasound unavailable) - aspiration of non-clotting blood from pouch of Douglas confirms haemoperitoneum

Note: With haemodynamic instability + syncope, this patient likely needs EMERGENCY LAPAROSCOPY without delay for confirmation + treatment.

Treatment

This is a SURGICAL EMERGENCY:

Resuscitation (simultaneous):

2 large-bore IV cannulae, IV fluids (crystalloids)
Blood crossmatch, transfusion if needed
Oxygen supplementation
Foley catheter + urine output monitoring
Urgent surgical consent

Surgical Treatment (definitive):

Emergency laparoscopy (preferred) or laparotomy if haemodynamically unstable
Salpingectomy (tube removal) - if tube severely damaged or for haemostasis; appropriate here given haemodynamic instability
Salpingotomy (linear salpingostomy) - conservative; considered if contralateral tube is absent/damaged and future fertility is paramount - but high risk of persistent trophoblast

Medical treatment (Methotrexate) is CONTRAINDICATED here because:

Haemodynamic instability
Evidence of rupture (syncope, low-volume pulse)
βhCG likely high

Post-operative:

Monitor βhCG to zero (ensure no persistent trophoblast)
Anti-D immunoglobulin if Rh-negative
Counsel on recurrence risk: 10-15% after first ectopic (Berek & Novak's Gynecology)
HSG after recovery to assess tubal patency of remaining tube
Early USS in any future pregnancy to confirm intrauterine location

Sources: Berek & Novak's Gynecology | S Das Manual on Clinical Surgery (13th Ed.) | Grainger & Allison's Diagnostic Radiology | ROSEN's Emergency Medicine | Sabiston Textbook of Surgery

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