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CASE PRESENTATION BY: VIDA SALVE ARQUILLO 2008-059 SAN BEDA COLLEGE OF MEDICINE.

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Presentation on theme: "CASE PRESENTATION BY: VIDA SALVE ARQUILLO 2008-059 SAN BEDA COLLEGE OF MEDICINE."— Presentation transcript:

1 CASE PRESENTATION BY: VIDA SALVE ARQUILLO SAN BEDA COLLEGE OF MEDICINE

2 IDENTIFICATION: D.D. 27 years-old Married Roman Catholic from Quezon City admitted for the first time at QMMC last May 5, 2011.

3 CHIEF COMPLAINT: Watery vaginal discharge

4 HISTORY OF PRESENT ILLNESS: 8 hours PTA clear watery vaginal discharge associated with abdominal pain -contracting -every 5-10 minutes -with a pain scale 5/10 -radiating to the pelvis and back No associated symptoms such as vomiting, fever and blurring of vision were noted.

5 HISTORY OF PRESENT ILLNESS: 3 hours PTA bloody vaginal discharge abdominal pain - pain scale of 8/10 - occurring more frequently - radiating to the back and pelvis. No other associated symptoms were noted.

6 HISTORY OF PRESENT ILLNESS: Due to the persistence of the abdominal pain and vaginal discharge and the suspicion of labor, the patient was rushed to the QMMC OB Emergency room.

7 REVIEW OF SYSTEMS: (-) rashes (-) dyspnea (-) change in urine color (-) weight loss (-) cough (-) change in stool color (-) jaundice (-) diarrhea (-) oliguria (-) dyspahagia (-)constipation (-) dysuria

8 OB HISTORY: LMP: August 5, 2010 EDC: May 12, 2011 AOG: 39 weeks by LMP

9 OB HISTORY: G5P4 (4004) GravidityYearMode of deliveryBirth weightComplications/outcome 12003NSD*largest baby is 3.o kg NONE 22006NSDNONE 32007NSDNONE 42009NSDNONE

10 OB HISTORY: Prenatal check-up: Culiat Quezon City health Center for four times Prenatal medications: Multivitamins – OD starting at the 1 st trimester until 3 rd trimester Ferrous sulfate – OD starting at 2 nd trimester until 3 rd trimester Prenatal disease/ infections: unremarkable

11 PAST MEDICAL HISTORY: Unremarkable FAMILY HISTORY: Unremarkable

12 MENSTRUAL HISTORY: Menarch at the age of 11 Duration of 3 to 5 days, regular Moderate flow, making used of 2-3 napkins a day Associated with abdominal and pelvic pain.

13 SEXUAL HISTORY: first coitus - age of 17 with one partner having 3-4 sexual intercourse a week.

14 CONTRACEPTIVE HISTORY: denies any history of contraceptive use. PERSONAL AND SOCIAL HISTORY: non-smoker occasional alcoholic drinker of 1 t0 2 times a month of 2 -3 bottles of beer denies any history of illicit drug use.

15 PHYSICAL EXAMINATIONS: General survey: well nourished looking, in pain, conscious, coherent, not in cardio respiratory distress. Vital Signs: BP: 110/60 HR: 80 bpm RR: 16 breaths/min Temp: afebrile (36. 3 °C)

16 PHYSICAL EXAMINATIONS: HEENT Head: scalp without lesions Eyes: anicteric sclera, pale conjunctiva, pupils equally reactive to light, extraocular movements intact Ears: no lesions, acuity good to whispered voice Nose: musoca is pink, midline septum, no mucosal discharge Mouth: moist pink oral mucosa, tongue midline, no exudates and inflammation, with poor dentition Neck: trachea midline, no lymphadenopathy Thyroid: palpable, not enlarged

17 PHYSICAL EXAMINATIONS: THORAX AND LUNGS: no scars, no lesion, no tenderness, with equal tactile fremiti, equal chest expansion, clear breath sounds, resonant on all lung fields CARDIOVASCULAR: apical impulse is discreet and tapping on 5 th ICS left midclavicular line, good S1 S2, no murmurs

18 PHYSICAL EXAMINATIONS: ABDOMEN: L1: hard,round, readily ballotable head L2: R – fetal parts, L – fetal back L3: buttocks / breech L4: not engaged Fundic height: 30 cm Fetal heart tone: 140’s/min

19 PHYSICAL EXAMINATIONS: INTERNAL EXAMINATION: Cervical dilatation: 8 cm Presentation: frank breech Station: -2 Effacement: 50% Bag of water: (-)

20 PHYSICAL EXAMINATIONS: EXTREMITIES: no scars, no lesion, CRT of less than 2 seconds, full pulses on all extremities, grade 2 edema on both lower extremities

21 DIAGNOSIS: ADMITTING DIAGNOSIS: G5P4 (4004) Pregnancy uterine 39 weeks AOG by LMP frank breech PRINCIPAL DIAGNOSIS: G5P5 (5005) Pregnancy uterine full term frank breech delivered via partial breech extraction to a live baby boy.

22 COURSE IN THE WARD: Day (date and time)Doctors ordersmedicinesLaboratoriesProcedures 5/5/11 Day 1 12:00 PM 2 pm Admitted to LR, NPO, IVF (D5LR 1L x 8º),Blood request, Monitor progress of labor, Inform pedia, refer Oxygen inhalation 2-3 lmp via nasal cannula, hook to pulse oximetry, monitor VS q15 x 2 hrs then q30 until stable, dat once fully awake, IVF D5LR 500cc + 10 units/min Monitor vital and record, refer accordingly Transfer to ward Continue medications Suggest BTL VS q4 DAT Refer accordingly - Cefalexin 500mg/cap, 1 cap TID for 7 days Mefenamic acid 500mg/ cap, 1 cap q6 on full stomach Ascorbic acid 500 mg 1 tab, 1 tab OD FeSO4 1 tab OD CBC and BT Baseline EFM Anesthesia via pudendal block, s/p NSD via PBE

23 COURSE IN THE WARD: Day (date and time)Doctors ordersmedicinesLaboratoriesProcedures 5/6/11 Day 2 (-) pallor (-) dizziness (+) porfuse vaginal bleeding (-) DOB (-) BOV IE ok 5/7/11 Day 3 CBC 5/8/11 Day 4 DAT For BTL, secure consent Continue meds Daily perineal hygiene Encourage brestfeeding Monitor VS q4 refer Shift cefalexin to ampisolbactam TPAG, CBC1 st degree dehiscence (-) pallor 5/10/11 Day 6 High protein diet, 2 egg white/meal Continue oral meds Daily perineal hygiene and full body bath Encourage breastfeeding VSq6 refer TP- 55 Albumin 24 GCAB – 31.8 A/G st degree dehiscence (-) pallor (-) profuse vaginal bledding (IE) No subjective complains (+) necrotic debris at dehisce site

24 COURSE IN THE WARD: Day (date and time)Doctors ordersmedicinesLaboratoriesProcedures 5/11/11 Day 7 Refused BTL Continue meds Inc. OFI Daily perineal hygiene and full body bath Encourage breastfeeding VSq4 refer 1 cm dehisce (-) necrotic tissue (-) discharge (-) pallor 5/12/11 Day 8 Patient advised but refused BTL May go home Continue oral meds Daily perineal hygiene gynepro TID full body bath Encourage breastfeeding Advised family planning OPD follow-up on 5/19 advised 1 cm dehisce (-) necrotic tissue (-) discharge (-) pallor

25 LABORATORY RESULTS Ultrasound (4/26/11) Uterus is regularly enlarged containing a single live male fetus breech presentation. FHT is 138 bpm. Absence of gross fetal abnormality. Amniotic fluid is normal/ placenta is posterior, high lying grade weeks and 1 day AOG. Estimated weight: 2543 g.

26 LABORATORY RESULTS Complete blood count (5/8/11) RBC – 4.13 (low) MCV – 79.9 (low) Hgb – 104 (low) MCH – 25.2 (low) Hct – 0.33 ( low) MCHC – 31.5 (low) RDW – (high) Platelet – 350 WBC – 12.8 (high)

27 LABORATORY RESULTS Blood chemistry (5/8/11) Total protein – 55.0 g/L (low) Albumin – 24.0 (low) Globulin – 31.9 A/G ratio – 0.8 (low)

28 LABORATORY RESULTS Urinalysis *Color – yellow *specific gravity – *Albumin and sugar – negative *WBC – 0-3 *RBC – 0-1 *Epithelial cells, bacteria, mucous threads - few

29 DISCUSSIONS I. Definition: Breech presentation – is when the buttocks of the fetus enter the pelvis first. Most often, however, the fetus turns spontaneously before the onset of labor so that breech presentation persist only about 3-4% of singleton deliveries.

30 DISCUSSIONS II. Types of Breech presentation FRANKCOMPLETE INCOMPLETE/FO OTLING

31 DISCUSSIONS III. Etiology/ Risk factors 1. gestational age 2. uterine relaxation associated with great parity 3. multiple fetuses 4. hydramnios 5. oligohydramnios 6. hydrocephalus 7. anencephalus 8. previous breech delivery 9. uterine anomaly 10. pelvic tumors

32 DISCUSSIONS IV. Complications of breech presentation 1. Perinatal morbidity and mortality 2. low birth weight from preterm delivery, growth restriction or both 3. prolapsed cord 4. placenta previa 5. fetal, neonatal and fetal anomalies 6. uterine anomalies and tumors 7. multiple fetuses 8 operative intervention (cesarian delivery)

33 DISCUSSIONS V. Diagnosis 1. Abdominal examination (Leopolds maneuver) 2. Vaginal Examination 3. Ultrasound

34 DISCUSSIONS VI. Management of Labor 1. Stage of Labor 2. Fetal condition 3. Fetal monitoring 4. Recruitment of nursing and medical personality

35 DISCUSSIONS VII. Delivery The choice of abdominal or vaginal delivery is based upon the following: 1. type of breech 2. flexion of the head 3. fetal size 4. quality of uterine contraction 5. size of maternal pelvis

36 DISCUSSIONS Recommendations for cesarian/abdominal delivery: 1. large fetus 2. any degree of contraction or unfavorable shape of the pelvis (platypelloid and android) 3. A hyperextended head (stargazer fetus/ the flying fetus – increased risk for injury of the spinal cord) 4. no labor with maternal indication (preeclampsia, ruptured membranes for 12 hours or more) 5. uterine dysfunction 6. footling presentation 7. preterm fetus of 25 to 26 weeks AOG or more, with the mother in active labor or in need of delivery 8. severe fetal growth restriction 9. previous perinatal death or children suffering form birth trauma 10. request for sterilization

37 DISCUSSIONS Vaginal Delivery Timing of delivery – the ability to proceed with immediate breech extraction should exist when the buttocks or feet appear at the vulva. - women with selected frank breech presentation estimated to be about 2000g or more but less than about 3500g are frequently offered planned vaginal delivery.

38 DISCUSSIONS Methods of vaginal delivery 1. Spontaneous breech delivery 2. Partial breech extraction 3. Total breech extraction.

39 DISCUSSIONS VII. Maneuvers for vaginal deliveries Mauriceau maneuver Prague maneuver

40 DISCUSSIONS VII. Maneuvers for vaginal deliveries Bracht maneuver USE OF FORCEPS

41 DISCUSSIONS VIII. Special topics A. Head entrapment – occasionally, especially with preterm infants. Gentle traction of the fetal body, the cervix at times, maybe manually slipped over the occiput, or do bracht maneuver, if not successful do dürhrssen incision in the cervix, if still unsuccessful do abdominal rescue which the replacement for the fetus higher into the vagina followed by cesarian delivery.

42 DISCUSSIONS B. Version – is the procedure in which the presentation of the fetus is altered artificially. 1. external version – performed exclusively on through the abdominal wall 2. internal version – entire hand is introduced into the uterine cavity.

43 DISCUSSIONS EXTERNAL VERSION/EXTERNAL CEPHALIC VERSION

44 DISCUSSIONS Indications for external cephalic version: 1. breech presentation is diagnosed in the last week of pregnancy 2. provided there is no marked feto- pelvis disproportion 3. provided there is no placenta previa Contraindication: women with previous cesarian delivery.

45 DISCUSSIONS Factors for successful version: 1. normal amniotic fluid 2. gestational age ( the earlier the better) 3. presenting part has not descended into the pelvis 4. fetal back is positioned posteriorly 5. woman is not obese

46 DISCUSSIONS Technique: Should be carried out in area that has already access to facility equipped for emergency cesarian delivery. Complications : 1. placental abruption 4. fetomaternal hemorrhage 2. uterine rupture 5. preterm labor 3. amniotic fluid embolism 6. fetal distress 7. fetal demise

47 THANK YOU!!!!! HAVE A GOOD DAY!!!!


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