Presentation on theme: "OBSTETRICS AND GYNECOLOGY CLINICO-PATHOLOGICAL CONFERENCE"— Presentation transcript:
1OBSTETRICS AND GYNECOLOGY CLINICO-PATHOLOGICAL CONFERENCE DEPARTMENT OFOBSTETRICS AND GYNECOLOGYCLINICO-PATHOLOGICAL CONFERENCEINOBSTETRTICSFrancisco, Jeff-rayFrancisco, ReinardGarcia, JenniferGarcia, Maria ReginaGarcia, Marla MarieGarcia, Roman Karlo
2CASE Chief Complaint: vaginal bleeding 32 year old female G4P2 (2012) AOG of 38th 2/7 weeksmarried, housewife, Roman Catholic, high school graduateLMP: November 6, 2008EDC: August 13, 2009Chief Complaint: vaginal bleeding
3HISTORY OF PRESENT ILLNESS Three hours PTABrownish discharge soiling her underwearVaginal bleeding of bright red blood4 fully soaked padsIrregular contractionsfrequency: 3-4 times/hrduration: secondsintensity: moderate
4OBSTETRIC HISTORY G1 G2 G3 G4 (present pregnancy) NSD; fullterm - Spontaneous abortion; S/P completion curettageG3Emergency CS for chromioamnionitis; fulltermno feto-maternal complicationsG4 (present pregnancy)With prenatal careUTI at 30 wks AOG; treated with cefalexin
5PAST HISTORY Coitarche at 24; (-) coital bleed/pain, STI OCP use for 2 years ( )(-) allergies, family history of HTN, DM, lung/cardiovascular diseases, cancer,(+) asthma, dysmenorrheaNon-smoker; non alcoholic beverage drinker
6PHYSICAL EXAMINATION General Survey: Vital Signs: HEENT: Conscious, coherent, ambulatory, NIRD.Vital Signs:BP- 110/70 mmHg, HR- 96 bpm,RR- 28 cpm, T- 36.5°CHEENT:Anicetric sclerae, pink conjunctivae; No tonsillopharyngeal congestion and cervical lymphadenopathy.Breasts: Symetric, no masses, tenderness, or nipple discharge.
7CVS: Chest and Lungs: Abdomen: Adynamic precordium, normal rate, regular rhythm, distinct S1 and S2, no murmurs.Chest and Lungs:Equal chest expansion, clear breath sounds.Abdomen:Globular, prsence of linea nigra,FH= 33cm, FHT= 140’s.Leopolds-I=breechII= fetal back maternal leftIII= Vertex, unenganged.
8Pelvic Exam:Inspection- Normal looking external genitalia, with continuous trickling of blood.Speculum and internal exam both not done.Extremities:With Grade 2 bipedal edema, pinkish nailbeds.
10Placenta previa, in hemorrhage. ADMITTING DIAGNOSISUterine pregnancy at 38 and 2/7 weeks AOG by LMP, Cephalic presentation but not in labor, G4P2 (2012) with 1 previous CS for chorioamnionitis in 2007;Placenta previa, in hemorrhage.
11COURSE IN THE WARDSon admission; underwent emergency classical cesarean section 1 with hysterectomyDelivery of a live full term baby girl (birth weight of kg, Birth length of 52 cm and APGAR score of 9 and 9)Blood loss of approximately 2,100 cc and blood transfusion with 3 units of PRBCThe patient had stable VS at the Recovery Room, and first post-operative day.The patient recuperated well until her discharge on the 4th post-operative day.
12SUBJECTIVE DATA 32 y/o female G4P2 (2012); AOG of 38 2/7 weeks Vaginal bleedingIrregular contractions of moderate intensityGood fetal movementHistory of spontaneous abortion; S/P completion curettageEmergency CSNon-smoker; non-alcolic beverage drinker
13OBJECTIVE DATA Normal VS Continuous trickling of blood on pelvic exam FH of 33cm; FHT of 140s (normal)Bipedal edema, grade 2CBC:low Hgb, Hct and RBC countslightly hypochromic, normocytic
15ABRUPTIO PLACENTA RULED IN: Risk factors: increasing maternal age, multiparityClinical presentation:Uterine bleedingInitially brownish discharge followed by bright red blood bleedPresence of Uterine contractions
16ABRUTIO PLACENTA RULED OUT absence of unremitting abdominal/back painAbsence of uterine tenderness, often hypertonic uterusAbsence of other risk factors;(hydramnios, diabetes mellitus, thrombophilias, uterine tumors like leiomyoma, nephropathy, fibroids, cigarette smoking, alcohol consumption of at least 14 drinks per week, cocaine use, abdominal trauma and maternal type O blood)- (-) signs of fetal distress
18PLACENTA PREVIA RULED IN: Risk factors Increasing maternal age MultiparityHistory of abortion, S/P completion curettageHistory of CS, chorioamnionitisClinical presentationPainless, persistent vaginal bleeding; bright red bloodPresence of contractions(-) signs of fetal distress; unangaged fetal head
19Placenta PreviaCondition in which the placenta implanted in the lower uterine segment within the zone of effacement and dilatation of the cervixLeading cause of 3rd trimester bleedingOccurs in 1:200 live birthsoften associated with placenta accreta.
20Diagnosis and Plan of Management Clinical presentation:Painless, persistent vaginal bleeding(-) signs of fetal distress; unengaged fetal head(-/+) uterine contractionsPresence of Risk Factors:Increasing maternal age, Multiparity, multiple gestation, abnormal vascularization of the endometrium caused by scarring or atrophy from previous trauma, surgery or infection, smoking, alcoholic beverages drinking…definitive diagnosis can be made via atransabdominal UTZ, ortransvaginal ultrasound
21Diagnosis and Plan of Management 2 possible approaches:cautious surveillance (watchful waiting)active approachDelivery of the babyManagement prior to delivery:correction of blood loss with intravenous fluidsBlood transfusion
22References1Kainer F, Hasbergen U. Emergencies Associated With Pregnancy and Delivery: Peripartum Hemorrhage. Dtsch Arztebl Int September; 105(37): 629–638.2Lala ABH, Rutherford JM. Massive or recurrent ante partum haemorrhage. Current Obstetrics and Gynaecology. 2002; 12: 226–230.3Kiondo P, Wandabwa J, Doyle P. Risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda. Afr Health Sci March; 8(1): 44–49.4Neilson JP. In: Ante partum Haemorrhage. Dewhurst text book of Obstetrics and Gynaecology for post graduate students. 6th Ed. Dewhurst , editor. London: Blackwell; 1999.5Cunningham FG, et al. Williams Obstetrics. 22nd ed. USA: McGraw-Hill Companies, IncSakornbut E, et al. Late pregnancy bleeding. American Family Physician. 2007;75:1199.The Merck Manual, 18th Edition. Abnormalities of Pregnancy: Abruptio placentae; Placenta previa :2191-2;Current Diagnosis and Treatment: Obstetrics and Gynecology, 10th editionRobbins Pathologic Basis of Disease. 7th edition.Board Review Series Pathology. Schneider 3rd edition.Wikepedia.org