Clinical cases/Case 2

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Meet the patient.

Case presentation[edit | edit source]

A primigravida visits the antenatal clinic at 39 weeks gestation to discuss her mode of delivery. She is 31 years old, had conceived soon after stopping combined oral contraceptive pills, had a routine ultrasound scan in the first trimester with no findings, and has reassuring medical, surgical and family histories.

Her pregnancy has been uneventful, with one minor exception. Between 34 and 39 weeks, her midwife repeatedly found the baby to have an unstable transverse lie, with the head palpable in various locations of the abdomen. Ultrasound scans by an obstetric ultrasonographer had not revealed a cause.

1 a) In general, which of the following sometimes cause unstable and/or transverse lie at 39 weeks?
    b) In general, which one is most likely to be overlooked by someone experienced in obstetric ultrasound on a routine prenatal ultrasound scan?

a) b)
Uterine fibroids
Pelvic inflammatory disease
Ectopic pregnancy
Placenta previa
Pelvic tumor
Down syndrome
Bicornuate uterus

2 What effect is transverse lie most likely to have on fundal height, compared to fundal height earlier in the pregnancy?

Increased fundal height
Decreased fundal height
No change

  • Question: In most pregnancies, how does fundal height at 39 weeks compare to earlier weeks?

On abdominal examination, the baby's head can be moved easily, and the option of external cephalic version with artificial rupture of membranes is discussed with the woman. To see whether this woman already has a ripe cervix, a vaginal examination is performed.


What is the eponymous name of the clinical score used to report the ripeness of the cervix?


  • Question: What elements are part of this score?

On vaginal examination, the patient is found to have a large, soft pelvic mass. A targeted transabdominal ultrasound scan reveals a heterogenous transparent intrapelvic mass of 9 x 10 centimeters, posteriolateral to the right of the cervix, with an inlying cystic structure and no associated ascites. Doppler flow analysis shows no feeding vessels.

  • Question: What is the appropriate mode of delivery for this woman?

Case discussion[edit | edit source]

Review questions

  • What are the possible differential diagnoses of ovarian cysts?
  • What is the appropriate management of ovarian cysts in pregnancy?

References[edit | edit source]

Suggested activities[edit | edit source]

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