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Presentation on theme: "OBSTETRICS-GYNECOLOGY CASE PRESENTATION"— Presentation transcript:

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. 40 year-old female Married Residing at Quezon City
Seen for the 1st time at the Quirino Memorial Medical Center-OB-Emergency Room on June 19, 2011


5 hours PTA Abdominal pain start from the back running towards her umbilicus contractions lasting for less than 5 minutes (2x in 5 minutes) Streak of blood form her vagina Persistence of the pain  Consult

5 2 hours after consult NSD to a live baby boy Blood loss (400-500 cc)
 RR

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

7 REVIEW OF SYSTEMS June 19, 2011 Unremarkable

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

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

High-school graduate Housewife Lives with her husband and 9 children Nonsmoker, non-alcohol beverage drinker Denies illicit drug use Diet - fish, vegetables, and rice Water source - NAWASA

11 OBSTETRIC HISTORY G10P10 (10-0-0-10) Year Mode of Delivery Place
Gender Complications G1 1990 NSD QMMC Female (-) G2 1992 Male G3 1994 G4 1996 G5 1997 G6 2001 G7 2005 G8 2007 G9 2009 G10 2011

12 LMP of last pregnancy AOG EDC September 22, 2010 38 weeks 4/7 by LMP
June 29, 2011

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

14 MENSTRUAL HISTORY Menarche - 12 y/o Regular Duration - 4-6 days
Interval days Moderate amount (2-3 pads/day) No dysmenorrhea/headache

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

1990 – Trust OCPs, discontinued 1996 – present - Coitus interruptus

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

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

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

20 Fetal Biometry: Measurement: Age of Gestation: Biparietal Diameter 9.3 cm 37 weeks and 1 day Femur Length 7.4 cm 38 weeks and 1 day Abdominal Circumference 34.1 cm 38 weeks and 2 days Head Circumference 33.5 cm 37 weeks and 6 days Estimated Fetal Weight: 3448 grams Impression: Pregnancy, 37 weeks and 6 days gestational age

21 LABORATORY TESTS June 19, 2011 Result Reference Range RBC Low 3.66
Hemoglobin 105 Hematocrit 0.32

22 June 20, 2011 Result Reference Range RBC Low 3.33 4.20-5.40 Hemoglobin
99 Hematocrit 0.30 Result Reference Range Hemoglobin Low 96 Hematocrit 0.28

Rh Group: +

24 June 21, 2011 Result Reference Range RBC Low 2.92 4.20-5.40 Hemoglobin
85 Hematocrit 0.26

25 June 21, 2001 BLOOD CHEMISTRY Test Name Result Reference Range Sodium
Low 135 Potassium 4.1 Chloride 104 97-107

26 June 21, 2011 PT, PTT Parameters Result Reference Range
Prothrombin Time 10.4 secs 10-14 secs PT INR 0.87 INR PT % Activity 119.2 % PT Normal Control 12.0 secs APTT 38.8 secs 28-44 secs APTT Normal Control 35.5 secs

27 June 22, 2011 Result Reference Range RBC Low 3.02 4.20-5.40 Hemoglobin
90 Hematocrit 0.27

28 June 23, 2011 Result Reference Range RBC Low 3.86 4.20-5.40 Hemoglobin
102 Hematocrit 0.34

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

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

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

32 Ketorolac 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/min Omeprazole 40 mg IV OD while on NPO Metoclopramide 10 mg PRN for vomiting Ampicillin 1 gram IV q 6° (-) ANST Metronidazole 500 mg IV q 8° x 3 doses (-)ANST Cconscious and coherent, with pallor. UO - adequate

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

34 SALIENT FEATURES 40 year-old, female G10P10 (10-0-0-10)
Blood loss of approximately 800 cc Tachycardic Pale palpebral conjunctiva Pale nail beds Low 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 Block

36 DISCUSSION 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.

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

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

39 Complications: vary, depends on the range of degree of severity Hypovolemia  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.  shock, anemia, infection, kidney failure, or brain damage

40 MANAGEMENT fundal massage is indicated
20 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 follow ergot derivatives: methylergonovine .2 mg, IM may cause hypertension prostaglandin: hemabate 250 grams, IM contraindicated in asthmatic px

41 if unresponsive to multiple administrations oxytocics:
bimanual uterine compression and fundal massage begin blood transfusions explore uterine cavity manually for retained placental fragments or lacerations thoroughly inspect the cervix and vagina after adequate exposure add 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)

42 ligation of arteries B-Lynch suturing of uterus




46 Intractable uterine atony  hysterectomy

47 Thank You.


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