1. Obstetrics Case Protocol
Block G: Calma, Capili, Coruna, Dagang, Datukon, Dayrit, de Castro, de la Llana, Gayeta, Golepang

2. General Data ST 29 year old primigravid Married Roman Catholic
from Las Pinas,

3. Reason for Consult
For prenatal checkup

4. Past Medical History
unremarkable

5. Family Medical History
unremarkable

6. Personal/Social/Sexual History
no vices
college undergraduate
first coitus was at 28 years old with one non promiscuous sexual partner
no history of use of OCPs, IUD, condoms, or any forms of contraception

7. Menstrual History Menarche at 15 years old
regular intervals, 4-5 days, 3-4 pads per day
no dysmenorrhea nor intermenstrual bleeding
LNMP: July 15, 2009
PMP: June 2009
AOG: 30 1/7 weeks by amenorrhea

8. Obstetric History
G1P0

9. History of Present Illness
6 months PTC:
(+) note of missed menses  consult with a private physician where a PT was done and was (+)
Pt asked to follow-up after 1 month

10. History of Present Illness
5 months PTC:
sudden onset hypogastric pain, “humihilab”, VAS 5/10, nonradiating.
no vaginal bleeding , watery vaginal discharge, fever or dysuria.
Consulted a local hopital where an UTZ was done: SLIUP, cephalic with AOG of 15 weeks and 5 days, normohydramnios, large IM and SS myoma in the lower anterior uterine segment more to the left side.

11. History of Present Illness
Due to unavailability of an obstetrician, pt was referred to a LH in Cavite for further management
Pt was admitted for 5 days, given unrecalled antibiotics, and was sent home
THM: Isoxilan 1 tab q6, Amoxicillin 500 mg/cap 1 cap TID x 5 days, Flagystatin suppository per vagina during bedtime x 4 days.

12. History of Present Illness
Pt continued to have her prenatal checkups with a private obstetrician.
Plan was for CS however, due to financial constraints, pt transferred to our institution for further management.

13. Review of Systems
(-) weight loss, anorexia, fever, blurring of vision, headache, vomiting, abdominal pain, watery or bloody vaginal discharge, dysuria, edema, decreased fetal movement.

14. Physical Examination awake, conscious, coherent, NICRD
BP 110/70, HR 80, RR 18, afebrile
anicteric sclera, pink conjunctivae, (-) cervical lymphadenopathy, (-) tonsillopharyngeal congestion, (-) anterior neck mass
equal chest expansion, clear breath sounds, (-) rales/wheezes
(-) thrills or heaves, distinct heart sounds, normal rate regular rhythm, (-) murmurs.

15. Physical Examination
Abdomen: globular, NABS, (+) 10 x 11 cm mass at the left lower quadrant, firm, movable and slightly tender
FH 37 cm, EFW kg, FHT 130s, RLQ, cephalic presentation
IE: NEG, smooth nulliparous vagina, cervix was soft, smooth, (-) AMT
FEP, PNB, (-) cyanosis, (-) edema.

16. Assessment
PU 36 2/7 weeks AOG EUTZ, CIPTL,
Myoma uteri
G1 P0.

17. Plan
Pt was sent to OBAS immediately due to preterm labor.

18. Ultrasonography TV and AP UTZ (09/20/2010)
Transvaginal and abdominopelvic ultrasound were done. Within the gravid uterus is a single live fetus in variable presentation. BPD measures 15 cm compatible with 15 weeks and 5 days. HC measures 11.9 cm compatible with 16 weeks and 0 days. AC measures 9.8 cm compatible with 15 weeks and 6 days. FL measures 1.7 cm compatible with 15 weeks and 2 days. There is good cardiac activity with FHR = 158 bpm. The amount of amniotic fluid appropriate for AOG. The immature placenta is posterior in location. EFBW = 130g. There is a huge well rounded heterogenous solid mass located in the lower anterior uterine segment left side of the uterus measuring 8.9 x 7.6 x 8.4 cm suggestive of myoma.

19. Ultrasonography Impression:
Single, live intrauterine pregnancy, cephalic with AOG of 15 weeks and 5 days. Normohydramnios. Large intramural and subserous myoma in the lower anterior uterine segment more to the left side.

20. Ultrasonography Fetal and Obstetrical Sonography (12/02/2009)
Number of fetus: single
Lie: Vertical breech
Somatic movement: active
Amniotic fluid: Anechoic normohydramnios
Placental location: Posterior grade0
Fetal HR: 134 bpm
Estimated fetal weight: 1030 g
Fetal sex: Male

21. ULtrasonography Biometry BPD 66 mm 27 weeks FL 49 mm 26 weeks
HC 240 mm 26 weeks
AC 219 mm 26 weeks
Estimated AOG: 26 weeks and 2 days
EDC: March 8, 2010

22. Ultrasonography Impression:
Within the gravid uterus is a sinle livefetus breech at present with estimated AOG of 26 weeks and 2 days by biometry. The fetus is active with good cardiac pulsation and normal amniotic fluid. Placenta is located posterior, high lying, with grade 0. No gross fetal anomaly. Note of left lateral wall myoma measuring 6.8 x 8 cm.

23. Guide Questions What are Uterine Myomas? What are the different types?
What is the pathophysiology of the development of myomas?
What are the forms of myoma degeneration? Differentiate each.
What are the effects of myomas in pregnancy?
What are the effects of pregnancy on myomas?

24. Guide Questions How should we work-up the patient?
How do we manage our patient?
What is the ideal management of myomas during pregnancy? Include medical and surgical management.