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Presentation on theme: "Page 1 DEPARTMENT OF OBSTETRICS AND GYNECOLOGY CLINICO-PATHOLOGICAL CONFERENCE IN OBSTETRTICS Francisco, Jeff-ray Francisco, Reinard Garcia, Jennifer Garcia,"— Presentation transcript:

1 Page 1 DEPARTMENT OF OBSTETRICS AND GYNECOLOGY CLINICO-PATHOLOGICAL CONFERENCE IN OBSTETRTICS Francisco, Jeff-ray Francisco, Reinard Garcia, Jennifer Garcia, Maria Regina Garcia, Marla Marie Garcia, Roman Karlo

2 Page 2 CASE 32 year old female G4P2 (2012) AOG of 38 th 2/7 weeks married, housewife, Roman Catholic, high school graduate LMP: November 6, 2008 EDC: August 13, 2009 Chief Complaint: vaginal bleeding

3 Page 3 HISTORY OF PRESENT ILLNESS Three hours PTA -Brownish discharge soiling her underwear -Vaginal bleeding of bright red blood -4 fully soaked pads -Irregular contractions frequency: 3-4 times/hr duration: seconds intensity: moderate

4 Page 4 OBSTETRIC HISTORY G1 - NSD; fullterm G2 - Spontaneous abortion; S/P completion curettage G3 -Emergency CS for chromioamnionitis; fullterm no feto-maternal complications G4 (present pregnancy) -With prenatal care -UTI at 30 wks AOG; treated with cefalexin

5 Page 5 PAST HISTORY -Coitarche at 24; (-) coital bleed/pain, STI -OCP use for 2 years ( ) -(-) allergies, family history of HTN, DM, lung/cardiovascular diseases, cancer, -(+) asthma, dysmenorrhea -Non-smoker; non alcoholic beverage drinker

6 Page 6 PHYSICAL EXAMINATION General Survey: -Conscious, coherent, ambulatory, NIRD. Vital Signs: BP- 110/70 mmHg, HR- 96 bpm, RR- 28 cpm, T- 36.5°C HEENT: -Anicetric sclerae, pink conjunctivae; No tonsillopharyngeal congestion and cervical lymphadenopathy. -Breasts: Symetric, no masses, tenderness, or nipple discharge.

7 Page 7 CVS: -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= 140s. Leopolds- I=breech II= fetal back maternal left III= Vertex, unenganged.

8 Page 8 Pelvic 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.

9 Page 9 8/1/098/3/09 Hgb Hct3136 RBC3.7 RBC morphology Slightly hypochromic, normocytic CBC result

10 Page 10 ADMITTING DIAGNOSIS Uterine 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.

11 Page 11 COURSE IN THE WARDS -on admission; underwent emergency classical cesarean section 1 with hysterectomy -Delivery 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 PRBC -The 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.

12 Page 12 SUBJECTIVE DATA -32 y/o female -G4P2 (2012); AOG of 38 2/7 weeks -Vaginal bleeding -Irregular contractions of moderate intensity -Good fetal movement -History of spontaneous abortion; S/P completion curettage -Emergency CS -Non-smoker; non-alcolic beverage drinker

13 Page 13 OBJECTIVE DATA -Normal VS -Continuous trickling of blood on pelvic exam -FH of 33cm; FHT of 140s (normal) -Bipedal edema, grade 2 -CBC: low Hgb, Hct and RBC count slightly hypochromic, normocytic

14 Page 14 DIFFERENTIAL DIAGNOSIS: Abruptio placenta

15 Page 15 ABRUPTIO PLACENTA RULED IN: Risk factors: -increasing maternal age, -multiparity Clinical presentation: -Uterine bleeding Initially brownish discharge followed by bright red blood bleed -Presence of Uterine contractions

16 Page 16 ABRUTIO PLACENTA RULED OUT -absence of unremitting abdominal/back pain -Absence of uterine tenderness, often hypertonic uterus -Absence 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

17 Page 17 PRIMARY IMPRESSION: Placenta previa

18 Page 18 PLACENTA PREVIA RULED IN: Risk factors -Increasing maternal age -Multiparity -History of abortion, S/P completion curettage -History of CS, chorioamnionitis Clinical presentation -Painless, persistent vaginal bleeding; bright red blood -Presence of contractions -(-) signs of fetal distress; unangaged fetal head

19 Page 19 Placenta Previa -Condition in which the placenta implanted in the lower uterine segment within the zone of effacement and dilatation of the cervix -Leading cause of 3 rd trimester bleeding -Occurs in 1:200 live births -often associated with placenta accreta.

20 Page 20 Diagnosis and Plan of Management Diagnosis: Clinical presentation: -Painless, persistent vaginal bleeding -(-) signs of fetal distress; unengaged fetal head -(-/+) uterine contractions Presence 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 a -transabdominal UTZ, or -transvaginal ultrasound

21 Page 21 Diagnosis and Plan of Management Management: 2 possible approaches: 1.cautious surveillance (watchful waiting) approach -Delivery of the baby Management prior to delivery: -correction of blood loss with intravenous fluids -Blood transfusion

22 Page 22 References 1Kainer 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; Cunningham FG, et al. Williams Obstetrics. 22nd ed. USA: McGraw-Hill Companies, Inc Sakornbut E, et al. Late pregnancy bleeding. American Family Physician. 2007;75:1199. The Merck Manual, 18th Edition. Abnormalities of Pregnancy: Abruptio placentae; Placenta previa. 2006:2191-2; Current Diagnosis and Treatment: Obstetrics and Gynecology, 10th edition Robbins Pathologic Basis of Disease. 7th edition. Board Review Series Pathology. Schneider 3rd edition.

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