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Katrina Mae Ramos SBC Medicine 2012

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

L.C., a 38 yo G3P2 (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

LMP: December 4, 2011 AOG: 28 1/7 wks

Few hours PTA Moderate bloody vaginal discharge; (+) hypogastric pain (Gr. 5/10) An hour PTA Profuse bloody vaginal discharge

5 ANTENATAL HISTORY 4 PNCUs at local health center
Daily multivitamins intake with FeSo4 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

Maternal & Paternal: u/r Personal/Social History: u/r

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 Gravida Year Term Place of Delivery Complications G1
1994 FT (NSD) home (-) G2 1996 G3 2011 Present Pregnancy


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 5th ICS LMCL, (-) heaves/thrills Auscultation: normal rate, regular rhythm, no murmurs

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 G3P2 (2002) Abruptio Placenta sec to PES

19 Plan: Trial of Labor Date of Operation: June 19, 2011 Post-Op Diagnosis: G3P3 (2102) IUFD 28 1/7 wks AOG del via NSD to a dead boy, Abruptio Placenta, PES

20 COURSE IN THE WARDS 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 COURSE IN THE WARDS 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)

22 LABORATORY TESTS CBC Results June 19 (Pre-Op) June 20 (Day 1 Post-Op)
RBC 2.20 (L) 2.75 (L) 3.07 (L) Hemoglobin 59 (L) 80 (L) 89 (L) Hematocrit 0.18 (L) 0.23 (L) 0.27 (L) WBC count 26.4 (H) 38.4 (H) 19.2 (H) Neutrophils 0.898 (H) 0.883 (H) N Lymphocyte 0.070 (L) 0.072 (L) 0.197 (H)

23 LABORATORY TESTS Coagulation June 19 (Pre-Op) June 21 (Day 2 Post-Op)
Prothrombin Time 12.3 9.1 (L) PT INR 1.02 0.76 PT % Activity 72.8 176.4 APTT 35.2 34.9

24 LABORATORY TESTS Blood Chemistry Glucose 3.42 (L) BUN 3.07 Crea
73.91 mmol/L AST 53 (H) Na 136 K 3.4 (L) Cl 101 Mg 0.88 AST (06/20/11) 48 (H)

25 ABRUPTIO PLACENTA “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 ABRUPTIO PLACENTA 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

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

28 ABRUPTIO PLACENTA: Signs & Symptoms
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 More common <19 or > 35 28 1/7 wks AOG ✔ 2nd & 3rd trimester
Salient Features Abruptio Placenta Placenta Previa PPROM 38 yo More common > 35 More common <19 or > 35 28 1/7 wks AOG 2nd & 3rd trimester Before 37 weeks Acute Vaginal bleeding magnitude of blood loss duration Variable Continuous 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 Findings abnormal placentation Oligohydramnios (-) fetal heart tone Internal Exam: 3 cm cervical dilatation, 50% effaced, cephalic presentation, floating, (+) BOW Pooling of blood Leaking bag of water Asst’d Hx Most common etiology: maternal HPN none Asst’d w/ other obstetric complications: multifetal gestation, breech, chorioamnionitis

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

31 ABRUPTIO PLACENTA 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

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 ABRUPTIO PLACENTA Vaginal Delivery Cesarean Delivery fetus is dead
live and mature fetus if vaginal delivery is not imminent

34 ABRUPTIO PLACENTA: Complications
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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