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OBSTETRICS-GYNECOLOGY CASE PRESENTATION YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino Memorial.

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Presentation on theme: "OBSTETRICS-GYNECOLOGY CASE PRESENTATION YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino Memorial."— Presentation transcript:

1 OBSTETRICS-GYNECOLOGY CASE PRESENTATION YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino Memorial Medical Center June 28, 2011

2 GENERAL DATA J.M.J.M. 40 year-old female40 year-old female MarriedMarried Residing at Quezon CityResiding at Quezon City Seen for the 1 st time at the Quirino Memorial Medical Center-OB-Emergency Room on June 19, 2011Seen for the 1 st time at the Quirino Memorial Medical Center-OB-Emergency Room on June 19, 2011

3 CHIEF COMPLAINT Labor painLabor pain

4 HISTORY OF PRESENT ILLNESS 5 hours PTA5 hours PTA Abdominal painAbdominal pain start from the back running towards her umbilicusstart from the back running towards her umbilicus contractions lasting for less than 5 minutes (2x in 5 minutes)contractions lasting for less than 5 minutes (2x in 5 minutes) Streak of blood form her vaginaStreak of blood form her vagina Persistence of the pain  ConsultPersistence of the pain  Consult

5 2 hours after consult2 hours after consult NSD to a live baby boyNSD to a live baby boy Blood loss ( cc)Blood loss ( cc)  RR  RR

6 3 hours after consult3 hours after consult Blood loss (300 cc)Blood loss (300 cc) Pale palpebral conjunctivaePale palpebral conjunctivae Pale nail bedsPale nail beds TachycardiacTachycardiac Persistence and progression  Immediate intervention Persistence and progression  Immediate intervention

7 REVIEW OF SYSTEMS June 19, 2011June 19, 2011 UnremarkableUnremarkable

8 PAST MEDICAL HISTORY No previous surgeries/hospitalizationsNo previous surgeries/hospitalizations No known allergies to food/medicationsNo known allergies to food/medications Immunizations unrecalledImmunizations unrecalled Chicken Pox – elementaryChicken Pox – elementary No known co-morbid illnessesNo known co-morbid illnesses No history of hypertension, Diabetes Mellitus, Pulmonary Tuberculosis, cancer, asthmaNo history of hypertension, Diabetes Mellitus, Pulmonary Tuberculosis, cancer, asthma

9 FAMILY HISTORY Cancer - MotherCancer - Mother (-) Diabetes Mellitus, thyroid diseases, cardiac diseases, pulmonary diseases, renal diseases(-) Diabetes Mellitus, thyroid diseases, cardiac diseases, pulmonary diseases, renal diseases

10 PERSONAL AND SOCIAL HISTORY High-school graduateHigh-school graduate HousewifeHousewife Lives with her husband and 9 childrenLives with her husband and 9 children Nonsmoker, non-alcohol beverage drinkerNonsmoker, non-alcohol beverage drinker Denies illicit drug useDenies illicit drug use Diet - fish, vegetables, and riceDiet - fish, vegetables, and rice Water source - NAWASAWater source - NAWASA

11 OBSTETRIC HISTORY G10P10 ( )G10P10 ( ) YearMode of DeliveryPlaceGenderComplications G11990NSDQMMCFemale(-) G21992NSDQMMCMale(-) G31994NSDQMMCFemale(-) G41996NSDQMMCFemale(-) G51997NSDQMMCMale(-) G62001NSDQMMCFemale(-) G72005NSDQMMCMale(-) G82007NSDQMMCMale(-) G92009NSDQMMCFemale(-) G102011NSDQMMCMale(-)

12 LMP of last pregnancyLMP of last pregnancy September 22, 2010September 22, 2010 AOGAOG 38 weeks 4/7 by LMP38 weeks 4/7 by LMP EDCEDC June 29, 2011June 29, 2011

13 ANTENATAL HISTORY 2 prenatal check-ups at health center2 prenatal check-ups at health center No prenatal diseases and infectionsNo prenatal diseases and infections Transabdominal ultrasound – 3 rd trimesterTransabdominal ultrasound – 3 rd trimester No abnormalities No abnormalities

14 MENSTRUAL HISTORY Menarche - 12 y/oMenarche - 12 y/o RegularRegular Duration daysDuration days Interval daysInterval days Moderate amount (2-3 pads/day)Moderate amount (2-3 pads/day) No dysmenorrhea/headacheNo dysmenorrhea/headache

15 SEXUAL HISTORY First coitus – 18 y/oFirst coitus – 18 y/o 1 sexual partner1 sexual partner No dysparenuria, post-coital bleeding, history of sexually transmitted diseasesNo dysparenuria, post-coital bleeding, history of sexually transmitted diseases

16 CONTRACEPTIVE HISTORY 1990 – Trust OCPs, discontinued1990 – Trust OCPs, discontinued 1996 – present - Coitus interruptus1996 – present - Coitus interruptus

17 PHYSICAL EXAMINATION June 19, 2011 – Upon AdmissionJune 19, 2011 – Upon Admission BP: 110/70 mmHg, supinePR: 80 bpm, regularBP: 110/70 mmHg, supinePR: 80 bpm, regular RR: 18 breaths/minTemp: 36.8  C, per axillaRR: 18 breaths/minTemp: 36.8  C, per axilla Conscious, coherent, ambulatory, not in cardio-respiratory distressConscious, coherent, ambulatory, not in cardio-respiratory distress HEENT: Anicteric sclerae, pink palepebral conjunctivaHEENT: Anicteric sclerae, pink palepebral conjunctiva Cardiovascular: Adynamic precordium, normal rate, regular rhythmCardiovascular: Adynamic precordium, normal rate, regular rhythm Abdomen: Round, FHT auscultated at 140s/minute on left lower quadrantAbdomen: Round, FHT auscultated at 140s/minute on left lower quadrant

18 Internal Exam:Internal Exam: Cervical dilatation: 7-8 cmCervical dilatation: 7-8 cm Effacement: 70 %Effacement: 70 % Presentation: CephalicPresentation: Cephalic Station: -2Station: -2 (+) Bag of Water(+) Bag of Water

19 DIAGNOSTIC EXAMINATIONS June 6, 2011June 6, 2011 OBSTETRIC TRANSABDOMINAL ULTRASONOGRAPHY OBSTETRIC TRANSABDOMINAL ULTRASONOGRAPHY Uterus is regularly enlargedUterus is regularly enlarged Single alive fetus, maleSingle alive fetus, male Cephalic presentationCephalic presentation Fetal heart rat e-142 bpmFetal heart rat e-142 bpm Absence of gross fetal abnormalityAbsence of gross fetal abnormality Normal Amniotic fluid volumeNormal Amniotic fluid volume RUQ- 3.0 cm, LUQ- 3.4 cm, RLQ- 4.0 cm, LLQ- 3.0 cm = cmRUQ- 3.0 cm, LUQ- 3.4 cm, RLQ- 4.0 cm, LLQ- 3.0 cm = cm Anterior, high-lying, with grade 2 maturity placentaAnterior, high-lying, with grade 2 maturity placenta Adnexae are clearAdnexae are clear

20 Fetal Biometry:Measurement:Age of Gestation: Biparietal Diameter9.3 cm37 weeks and 1 day Femur Length7.4 cm38 weeks and 1 day Abdominal Circumference34.1 cm38 weeks and 2 days Head Circumference33.5 cm37 weeks and 6 days Estimated Fetal Weight: 3448 grams Impression: Pregnancy, 37 weeks and 6 days gestational age

21 LABORATORY TESTS June 19, 2011June 19, 2011 ResultReference Range RBCLow HemoglobinLow HematocritLow

22 June 20, 2011June 20, 2011 ResultReference Range RBCLow HemoglobinLow HematocritLow ResultReference Range HemoglobinLow HematocritLow

23 June 20, 2011June 20, 2011 BLOOD TYPING AND CROSSMATCHING RESULTS Blood Type: A Rh Group: +

24 June 21, 2011June 21, 2011 ResultReference Range RBCLow HemoglobinLow HematocritLow

25 June 21, 2001June 21, 2001 BLOOD CHEMISTRY Test NameResultReference Range SodiumLow Potassium Chloride

26 June 21, 2011June 21, 2011 PT, PTT ParametersResultReference Range Prothrombin Time10.4 secs10-14 secs PT INR0.87 INR PT % Activity119.2 % PT Normal Control12.0 secs10-14 secs APTT38.8 secs28-44 secs APTT Normal Control35.5 secs28-44 secs

27 June 22, 2011June 22, 2011 ResultReference Range RBCLow HemoglobinLow HematocritLow

28 June 23, 2011June 23, 2011 ResultReference Range RBCLow HemoglobinLow HematocritLow

29 COURSE IN THE WARDS June 19, 2011June 19, 2011 Gave birth via normal spontaneous delivery to a baby boyGave birth via normal spontaneous delivery to a baby boy Oxytocin IMOxytocin IM Total blood loss ( cc)Total blood loss ( cc) 10 ”u” of oxytocin - incorporated in IVF10 ”u” of oxytocin - incorporated in IVF Cefalexin 500 mg/cap q 8° x 7 daysCefalexin 500 mg/cap q 8° x 7 days Mefenamic acid 500 mg/cap q 6°, PRN for painMefenamic acid 500 mg/cap q 6°, PRN for pain CXR PA view, Na, K, Cl, AST, ALT, LDH, UACXR PA view, Na, K, Cl, AST, ALT, LDH, UA NPONPO

30 June 20, 2011June 20, 2011 Blood loss (300 cc)Blood loss (300 cc) Pale palpebral conjunctivae, pale nail beds, and tachycardiac ( bpm)Pale palpebral conjunctivae, pale nail beds, and tachycardiac ( bpm) Hemoglobin and hematocrit (99,.030)Hemoglobin and hematocrit (99,.030) For emergency hysterectomy secondary to uterine atonyFor emergency hysterectomy secondary to uterine atony Ampicillin 2 grams/IV, (-) ANSTAmpicillin 2 grams/IV, (-) ANST 1 unit Voluven1 unit Voluven

31 Underwent emergency Total Abdominal Hysterectomy under subarachnoid blockUnderwent emergency Total Abdominal Hysterectomy under subarachnoid block Vital signs - stableVital signs - stable 2 units of PRBCs - transfused 2 units of PRBCs - transfused Blood loss intra-op ccBlood loss intra-op cc

32 Ketorolac 30 mg IV loading, then 15 mg IV q 6° x 4 doses (-) ANSTKetorolac 30 mg IV loading, then 15 mg IV q 6° x 4 doses (-) ANST Tramadol 150 mg loading then Tramadol drip 300 mg in 500 cc D5W at 21 gtts/minTramadol 150 mg loading then Tramadol drip 300 mg in 500 cc D5W at 21 gtts/min Omeprazole 40 mg IV OD while on NPOOmeprazole 40 mg IV OD while on NPO Metoclopramide 10 mg PRN for vomitingMetoclopramide 10 mg PRN for vomiting Ampicillin 1 gram IV q 6° (-) ANSTAmpicillin 1 gram IV q 6° (-) ANST Metronidazole 500 mg IV q 8° x 3 doses (-)ANSTMetronidazole 500 mg IV q 8° x 3 doses (-)ANST Cconscious and coherent, with pallor. UO - adequateCconscious and coherent, with pallor. UO - adequate

33 June 21, 2011 and June 22, 2011June 21, 2011 and June 22, 2011 Same managementSame management June 23, 2011June 23, 2011 Hemoglobin and hematocrit - slightly below baselineHemoglobin and hematocrit - slightly below baseline Clearance for possible dischargeClearance for possible discharge

34 SALIENT FEATURES 40 year-old, female40 year-old, female G10P10 ( )G10P10 ( ) Blood loss of approximately 800 ccBlood loss of approximately 800 cc TachycardicTachycardic Pale palpebral conjunctivaPale palpebral conjunctiva Pale nail bedsPale nail beds Low Hemoglobin and HematocritLow Hemoglobin and Hematocrit

35 DIAGNOSIS G10P10 ( ) PUFT, cephalic, delivered via NSD to a live baby boy with AS 9, Postpartum Hemorrhage secondary to Uterine Atony, S/P Total Abdominal Hysterectomy by Subarachnoid BlockG10P10 ( ) PUFT, cephalic, delivered via NSD to a live baby boy with AS 9, Postpartum Hemorrhage secondary to Uterine Atony, S/P Total Abdominal Hysterectomy by Subarachnoid Block

36 DISCUSSION Uterine Atony is the failure of the uterus to contract properly following delivery.Uterine Atony is the failure of the uterus to contract properly following delivery. Failure of contraction and retraction of the myometrium prevents hemostasis and leads to an increase in blood loss.Failure of contraction and retraction of the myometrium prevents hemostasis and leads to an increase in blood loss.

37 Predisposing factors:Predisposing factors: high parityhigh parity precipitous or prolonged laborprecipitous or prolonged labor general anesthesiageneral anesthesia overdistended uterus (macrosomia, hydramnios, multifetal pregnancy)overdistended uterus (macrosomia, hydramnios, multifetal pregnancy) oxytocin augmentation or induction of laboroxytocin augmentation or induction of labor history of PPHhistory of PPH amniotic fluid embolismamniotic fluid embolism magnesium sulfate in laboring patientsmagnesium sulfate in laboring patients constant kneading and squeezingconstant kneading and squeezing

38 Uterine Atony VS Vaginal LacerationsUterine Atony VS Vaginal Lacerations based on the condition of the uterusbased on the condition of the uterus uterus - soft and boggy following infant and placental deliveryuterus - soft and boggy following infant and placental delivery once uterus is well contracted, but still (+) bright-red bleeding  lacerationsonce uterus is well contracted, but still (+) bright-red bleeding  lacerations

39 Complications:Complications: vary, depends on the range of degree of severityvary, depends on the range of degree of severity Hypovolemia  maternal hypotension, shock, acute tubular necrosis, dilution coagulopathy, cardiac arrest, and deathHypovolemia  maternal hypotension, shock, acute tubular necrosis, dilution coagulopathy, cardiac arrest, and death BT-related complications – BT reactions, hemolysis d/t ABO incompatibility, viral diseases (hepatitis & HIV infection), acute lung injury, transmission of bacterial endotoxin, transmission of parasitic agents, graft VS host disease, alloimmunization to blood products, and transfusion-related immunosuppression.BT-related complications – BT reactions, hemolysis d/t ABO incompatibility, viral diseases (hepatitis & HIV infection), acute lung injury, transmission of bacterial endotoxin, transmission of parasitic agents, graft VS host disease, alloimmunization to blood products, and transfusion-related immunosuppression.  shock, anemia, infection, kidney failure, or brain damage  shock, anemia, infection, kidney failure, or brain damage

40 MANAGEMENT fundal massage is indicatedfundal massage is indicated 20 units of oxytocin in 1 L of LR or PNSS, IV, 10 ml/min20 units of oxytocin in 1 L of LR or PNSS, IV, 10 ml/min oxytocin should never be given as an undiluted bolus dose as serious hypotension or cardiac arrhythmias may followoxytocin should never be given as an undiluted bolus dose as serious hypotension or cardiac arrhythmias may follow ergot derivatives: methylergonovine.2 mg, IMergot derivatives: methylergonovine.2 mg, IM may cause hypertensionmay cause hypertension prostaglandin: hemabate 250 grams, IMprostaglandin: hemabate 250 grams, IM contraindicated in asthmatic pxcontraindicated in asthmatic px

41 if unresponsive to multiple administrations oxytocics:if unresponsive to multiple administrations oxytocics: bimanual uterine compression and fundal massagebimanual uterine compression and fundal massage begin blood transfusionsbegin blood transfusions explore uterine cavity manually for retained placental fragments or lacerationsexplore uterine cavity manually for retained placental fragments or lacerations thoroughly inspect the cervix and vagina after adequate exposurethoroughly inspect the cervix and vagina after adequate exposure add a second large-bore intravenous catheter at the same time as blood is givenadd a second large-bore intravenous catheter at the same time as blood is given insert a foley catheter to monitor urine output (good renal perfusion measure)insert a foley catheter to monitor urine output (good renal perfusion measure)

42 ligation of arteriesligation of arteries B-Lynch suturing of uterusB-Lynch suturing of uterus

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46 Intractable uterine atony  hysterectomyIntractable uterine atony  hysterectomy

47 Thank You. Thank You.


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