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Characteristics of a normal cervix are: consistency is smooth and firm; contour is evenly rounded;

and mobility is flexible. An abnormal cervix would be firm, fixed, possibly nodular, and painful

when moved.

Chapter 12

The Pregnant Woman

Case Study: Irregular Menses

WHAT PARTS OF THE EXAM WOULD YOU LIKE TO PERFORM?

General survey

Vital signs

 Abdomen

Female genitalia

BASED ON THIS INFORMATION, WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

Primary amenorrhea

Primary amenorrhea by definition means that the patient has not had periods (usually by

age 16). In this case, the patient has been having regular menstruation until 4 months prior to the

onset of amenorrhea.

Missed abortion 

This is less likely. In the event of a missed abortion, the patient usually experiences

 

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vaginal bleeding that is heavier than her usual menses. This has not occurred in our patient. Her

menstruation has become less, not more.

Pregnancy (most likely diagnosis)

The patient has not had a menstrual cycle in 4 months; she has experienced symptoms

consistent with early pregnancy, such as nausea and fatigue. Intermittent spotting can occur

during pregnancy. Intermittent spotting can be caused by vaginal or urinary tract infections, or

sexual intercourse. Upon physical examination, the cervix will appear bluish and at the stage of

development of our patient, may be more difficult to locate, secondary to being positioned more

posteriorly. Also, upon physical examination, an enlarged uterus is palpable in this scenario,

which further increases the suspicion of pregnancy. A urine or blood test will be required to

confirm the diagnosis.

Ryan: Kistner’s Gynecology & Women’s Health, 7th ed., Mosby, Inc. 1999.

Chapter 12 – Pediatric and Adolescent Gynecology

Marc R. Laufer and Donald P. Goldstein

Multiple Choice

1. The correct answer is (B) Recommend that the best time to perform BSE is 4–7 days after

the first day of the menstrual period

Help each woman establish a regular schedule of self-care. The best time to conduct breast self-

examination is right after the menstrual period, or the fourth through the seventh day of the

menstrual cycle, when estrogen stimulation is low and the breasts are least congested. Advise

the pregnant woman or menopausal woman who is not having menstrual periods to select a

 

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familiar date to examine her breasts each month, for example, her birth date or the day the rent is

due.

2. The correct answer is (C) Hegar’s sign and Goodell’s sign

Shortly after the first missed menstrual period, the female genitalia show signs of the hormonal

changes of pregnancy. The cervix softens (Goodell’s sign) at 4–6 weeks, and the vaginal mucosa

and the isthmus of the uterus softens (Hegar’s sign) at 6–8 weeks.

The cervix looks cyanotic (Chadwick’s sign) at 8–12 weeks. These changes reflect increased

vascularity and edema of the cervix, and hypertrophy and hyperplasia of the cervical glands.

Tanner’s signs refer to sexual maturity ratings in adolescents.

3. Mrs. W is in her first trimester of pregnancy. She is experiencing significant nausea and

vomiting and asks if it will get better. Your response is:

(A) “At about the time the baby moves, it will get better.’’

(B) “Many women experience nausea and vomiting until the third trimester.”

(C) “Did your mother have significant nausea and vomiting?”

(D) “Usually, by the beginning of the second trimester, the nausea and vomiting improve.”

The correct answer is (D) “Usually, by the beginning of the second trimester, the nausea and

vomiting improve.”