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OB-GYN CASE REPORT Katrina Mae Ramos SBC Medicine 2012.

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Presentation on theme: "OB-GYN CASE REPORT Katrina Mae Ramos SBC Medicine 2012."— Presentation transcript:

1 OB-GYN CASE REPORT Katrina Mae Ramos SBC Medicine 2012

2 GEN DATA and CHIEF COMPLAINT L.C., a 38 yo G 3 P 2 (2002), married Filipino, Catholic, presently residing at Brgy Holy Spirit, Quezon City admitted at QMMC last June 19, 2011 Chief Complaint: vaginal bleeding x few hrs

3 HISTORY OF PRESENT PREGNANCY  LMP: December 4, 2011  AOG: 28 1/7 wks

4 HISTORY OF PRESENT PREGNANCY Few hours PTA Moderate bloody vaginal discharge; (+) hypogastric pain (Gr. 5/10) An hour PTAProfuse bloody vaginal discharge

5 ANTENATAL HISTORY  4 PNCUs at local health center  Daily multivitamins intake with FeSo 4  Good diet with regular intake of milk and water

6 REVIEW OF SYSTEMS  General Survey: (-) weight gain, fever, chills,  Skin: (-) rashes, pruritus  Head and Neck: (-) headache  CNS: (-) loss of consciousness, nausea  CVS: (-) easy fatigability, palpitations  Respiratory: (-) difficulty of breathing, chest pain, cough, hemoptysis  GIT: (-) vomiting, polydipsia, vomiting, dysphagia  GUT: (-) polyuria, diarrhea, constipation, dysuria, hematuria  Musculoskeletal: (+) pelvic pain, (+) bipedal edema

7 PAST MEDICAL HISTORY  (+) HPN – 2011  (-) DM, heart dse, PTB, anemia  (-) prior surgery, trauma, blood transfusions  (-) allergies to food or meds

8 FAMILY HISTORY PERSONAL & SOCIAL HISTORY  Maternal & Paternal: u/r  Personal/Social History: u/r

9 MENSTRUAL & SEXUAL HISTORY  Menarche : 14 yo  Interval: regular, days  Duration: 3-4 days  Amount: 1-2 pads/days  Sx: none Sexual History  Coitarche: 17 yo with her husband  (-) STDs

10 OBSTETRIC HISTORY GravidaYearTermPlace of Delivery Complications G1G1 1994FT (NSD)home(-) G2G2 1996FT (NSD)home(-) G3G3 2011Present Pregnancy

11 CONTRACEPTIVE HISTORY  none

12 PHYSICAL EXAM: General Survey  conscious, coherent, ambulatory, NICRD Vital Signs:  BP: 140/110 mmHg  HR: 92 bpm  RR: 18  Temp: 37.1°C

13 PHYSICAL EXAM: Head & Neck  SKIN: good skin turgor, (-) clubbing and cyanosis HEENT:  Head: normocephalic  Eyes: not bulging or protruding, pale palpebral conjunctiva, anicteric sclera,  Ears: (-) visible masses, tenderness, discharge  Nose: symmetrical, midline septum, no nasal flaring  Throat: moist oral mucosa, no swelling,tongue midline, (-) TPC  Neck: supple neck, trachea on midline, thyroid is not enlarged, (-) LAD

14 PHYSICAL EXAM: Thorax  Inspection: no supraclavicular or intercostal retractions, (-) use of accessory muscles, no masses, lesions,  Palpation: (-) tenderness, symmetrical chest expansion  Percussion: resonant  Auscultation: clear breath sounds

15 PHYSICAL EXAM: CVS  Inspection: no visible pulses  Palpation: AB palpated at 5 th ICS LMCL, (-) heaves/thrills  Auscultation: normal rate, regular rhythm, no murmurs

16 PHYSICAL EXAM: Abdomen  Inspection: abdomen globular; (-) visible pulsations, dilated veins; (+) linea nigra, (+) striae gravidarum  Auscultation: NABS, (-) organomegaly, FHT: not appreciated by stet & doppler  Palpation: FH=28 cm

17 PHYSICAL EXAM: Pelvic  Internal Exam (IE): 3 cm cervical dilatation, 50% effaced, cephalic presentation, floating, (+) BOW  EXTREMITIES: (+) pallor, (+) bipedal edema, no cyanosis, +2 pulses on both extremities

18 ADMITTING DIAGNOSIS IUFD 28 1/7 wks AOG CIBL G 3 P 2 (2002) Abruptio Placenta sec to PES

19  Plan: Trial of Labor  Date of Operation: June 19, 2011  Post-Op Diagnosis: G 3 P 3 (2102) IUFD 28 1/7 wks AOG del via NSD to a dead boy, Abruptio Placenta, PES

20 June 19, 2011 (Date of Admission)  NPO, vital signs monitoring q1, IFC  Diagnostics ordered: CBC with APC & BT, PT/PTT, CT & BT, UA, BUN, Crea, AST, ALT, LDH, Na, K, Cl  Meds ordered: MgSO4, Hydra 5mg TIV q20 mins (>160/100)  Internal Exam (IE): 4 cm, 60% effaced, st. -2, (-) BOW after 2 hrs  hypertensive; other vital signs were stable  For LTCS I + BTL  7:30 PM s/p NSD IVF with oxytocin advised to start oral meds: Cefuroxime, Mefenamic Acid, Methyldopa, FeSo4

21 June 20, 2011 (Day 1 Post-Op)  BP: 120/90; stable vital signs  repeat laboratory test was done  2 “u” pRBC was transfused June 21, 2011 (Day 2 Post-Op)  additional 1 “u” of pRBC was transfused June 22, 2011 (Day 3 Post-Op)  additional 1 “u” of pRBC was transfused

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25  “accidental hemorrhage”  Incidence: 1/100-1/200 deliveries  Common cause of intrauterine fetal demise  Occurs when all or part of the placenta separates from the underlying uterine attachment  premature separation of the normally implanted placenta

26 Degree of Detachment:  Partial  Complete As to Onset  Acute  Chronic As to Type  External hemorrhage – bet. the membranes and uterus  Concealed hemorrhage – retained bet the detached placenta and uterus  Marginal sinus rupture – limited to the edge

27  Chronic HPN  Increased age and parity  Preeclampsia  PROM  Thrombophilias  Maternal trauma  Prior abruption  Smoking  Cocaine use  Uterine leiomyoma

28  Vaginal bleeding* - 80%  Abdominal or back pain and uterine tenderness - 70%  Fetal distress* - 60%  Abnormal uterine contractions (eg, hypertonic, high frequency)* - 35%  Idiopathic premature labor - 25%  Fetal death - 15%

29 Salient FeaturesAbruptio PlacentaPlacenta PreviaPPROM 38 yoMore common > 35More common /7 wks AOG ✔ 2 nd & 3rd trimester ✔ 2 nd & 3 rd trimester ✔ Before 37 weeks Acute ✔✔ Vaginal bleeding  magnitude of blood loss  duration ✔ Variable Continuous ✔ Variable Often ceases w/in 1-2 hrs Moderate  profuse ✔✔ Sudden gush of Variable quantity of clear or slightly turbid, nearly colorless liquid Red (bright) ✔✔ Painful ✔ UTZ Findingsabnormal placentationOligohydramnios (-) fetal heart tone ✔ Internal Exam: 3 cm cervical dilatation, 50% effaced, cephalic presentation, floating, (+) BOW ✔ Pooling of bloodLeaking bag of water Asst’d Hx Most common etiology: maternal HPN none Asst’d w/ other obstetric complications: multifetal gestation, breech, chorioamnionitis

30  Clot formation retroplacentally  Ultrasonography and doppler imaging  Non-specific markers (thrombomodulin) – significantly elevated

31 Hemorrhage into the decidua basalis ↓ Decidua splits (thin layer adherent to the myometrium) ↓ Decidual hematoma ↓ Separation, compression and destruction placenta ↓ Examination of freshly discovered organ: circumscribed depression measuring few cms in diameter on its maternal surface and covered by dark, clotted blood

32  Institute crystalloid fluid resuscitation for the patient (D5LR or D5W)  Monitor and control of BP, PR, RR, urinary output  Blood samples drawn for baseline hematocrit, coagulation studies, blood typing, and crossmatching  Treatment of associated DIC involves delivery of the fetus and placenta, restoration of maternal blood volume, and correction of coagulation with the use of blood components

33  Vaginal Delivery  fetus is dead  Cesarean Delivery  live and mature fetus  if vaginal delivery is not imminent

34  Couvelaire uterus  extravasation of blood into the uterine musculature and beneath the uterine serosa  blue or purple  Acute Renal Failure  massive hemorrhage  impaired renal perfusion  Consumptive Coagulopathy


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