1. Katrina Mae Ramos SBC Medicine 2012
OB-GYN CASE REPORT
Katrina Mae Ramos
SBC Medicine 2012

2. GEN DATA and CHIEF COMPLAINT
L.C., a 38 yo G3P2 (2002), married Filipino, Catholic, presently residing at Brgy Holy Spirit, Quezon City admitted at QMMC last June 19, 2011
Chief Complaint: vaginal bleeding x few hrs

3. HISTORY OF PRESENT PREGNANCY
LMP: December 4, 2011
AOG: 28 1/7 wks

4. HISTORY OF PRESENT PREGNANCY
Few hours PTA
Moderate bloody vaginal discharge; (+) hypogastric pain (Gr. 5/10)
An hour PTA
Profuse bloody vaginal discharge

5. ANTENATAL HISTORY 4 PNCUs at local health center
Daily multivitamins intake with FeSo4
Good diet with regular intake of milk and water

6. REVIEW OF SYSTEMS General Survey: (-) weight gain, fever, chills,
Skin: (-) rashes, pruritus
Head and Neck: (-) headache
CNS: (-) loss of consciousness, nausea
CVS: (-) easy fatigability, palpitations
Respiratory: (-) difficulty of breathing, chest pain, cough, hemoptysis
GIT: (-) vomiting, polydipsia, vomiting, dysphagia
GUT: (-) polyuria, diarrhea, constipation, dysuria, hematuria
Musculoskeletal: (+) pelvic pain, (+) bipedal edema

7. PAST MEDICAL HISTORY (+) HPN – 2011 (-) DM, heart dse, PTB, anemia
(-) prior surgery, trauma, blood transfusions
(-) allergies to food or meds

8. FAMILY HISTORY PERSONAL & SOCIAL HISTORY
Maternal & Paternal: u/r
Personal/Social History: u/r

9. MENSTRUAL & SEXUAL HISTORY
Menarche : 14 yo
Interval: regular, days
Duration: 3-4 days
Amount: 1-2 pads/days
Sx: none
Sexual History
Coitarche: 17 yo with her husband
(-) STDs

10. OBSTETRIC HISTORY Gravida Year Term Place of Delivery Complications G1
1994
FT (NSD)
home
(-) G2
1996 G3
2011
Present Pregnancy

11. CONTRACEPTIVE HISTORY
none

12. PHYSICAL EXAM: General Survey
conscious, coherent, ambulatory, NICRD
Vital Signs:
BP: 140/110 mmHg
HR: 92 bpm
RR: 18
Temp: 37.1°C

13. PHYSICAL EXAM: Head & Neck
SKIN: good skin turgor, (-) clubbing and cyanosis
HEENT:
Head: normocephalic
Eyes: not bulging or protruding, pale palpebral conjunctiva, anicteric sclera,
Ears: (-) visible masses, tenderness, discharge
Nose: symmetrical, midline septum, no nasal flaring
Throat: moist oral mucosa, no swelling,tongue midline, (-) TPC
Neck: supple neck, trachea on midline, thyroid is not enlarged, (-) LAD

14. PHYSICAL EXAM: Thorax
Inspection: no supraclavicular or intercostal retractions, (-) use of accessory muscles, no masses, lesions,
Palpation: (-) tenderness, symmetrical chest expansion
Percussion: resonant
Auscultation: clear breath sounds

15. PHYSICAL EXAM: CVS Inspection: no visible pulses
Palpation: AB palpated at 5th ICS LMCL, (-) heaves/thrills
Auscultation: normal rate, regular rhythm, no murmurs

16. PHYSICAL EXAM: Abdomen
Inspection: abdomen globular; (-) visible pulsations, dilated veins; (+) linea nigra, (+) striae gravidarum
Auscultation: NABS, (-) organomegaly, FHT: not appreciated by stet & doppler
Palpation: FH=28 cm

17. PHYSICAL EXAM: Pelvic
Internal Exam (IE): 3 cm cervical dilatation, 50% effaced, cephalic presentation, floating, (+) BOW
EXTREMITIES: (+) pallor, (+) bipedal edema, no cyanosis, +2 pulses on both extremities

18. ADMITTING DIAGNOSIS
IUFD 28 1/7 wks AOG CIBL G3P2 (2002) Abruptio Placenta sec to PES

19. Plan: Trial of Labor
Date of Operation: June 19, 2011
Post-Op Diagnosis:
G3P3 (2102) IUFD 28 1/7 wks AOG del via NSD to a dead boy, Abruptio Placenta, PES

20. COURSE IN THE WARDS June 19, 2011 (Date of Admission)
NPO, vital signs monitoring q1, IFC
Diagnostics ordered: CBC with APC & BT, PT/PTT, CT & BT, UA, BUN, Crea, AST, ALT, LDH, Na, K, Cl
Meds ordered: MgSO4, Hydra 5mg TIV q20 mins (>160/100)
Internal Exam (IE): 4 cm, 60% effaced, st. -2, (-) BOW after 2 hrs
hypertensive; other vital signs were stable
For LTCS I + BTL
7:30 PM s/p NSD
IVF with oxytocin
advised to start oral meds: Cefuroxime, Mefenamic Acid, Methyldopa, FeSo4

21. COURSE IN THE WARDS June 20, 2011 (Day 1 Post-Op)
BP: 120/90; stable vital signs
repeat laboratory test was done
2 “u” pRBC was transfused
June 21, 2011 (Day 2 Post-Op)
additional 1 “u” of pRBC was transfused
June 22, 2011 (Day 3 Post-Op)

22. LABORATORY TESTS CBC Results June 19 (Pre-Op) June 20 (Day 1 Post-Op)
RBC
2.20 (L)
2.75 (L)
3.07 (L)
Hemoglobin
59 (L)
80 (L)
89 (L)
Hematocrit
0.18 (L)
0.23 (L)
0.27 (L)
WBC count
26.4 (H)
38.4 (H)
19.2 (H)
Neutrophils
0.898 (H)
0.883 (H) N
Lymphocyte
0.070 (L)
0.072 (L)
0.197 (H)

23. LABORATORY TESTS Coagulation June 19 (Pre-Op) June 21 (Day 2 Post-Op)
Prothrombin Time
12.3
9.1 (L)
PT INR
1.02
0.76
PT % Activity
72.8
176.4
APTT
35.2
34.9

24. LABORATORY TESTS Blood Chemistry Glucose 3.42 (L) BUN 3.07 Crea
73.91 mmol/L
AST
53 (H) Na
136 K
3.4 (L) Cl
101 Mg
0.88
AST (06/20/11)
48 (H)

25. ABRUPTIO PLACENTA “accidental hemorrhage”
Incidence: 1/100-1/200 deliveries
Common cause of intrauterine fetal demise
Occurs when all or part of the placenta separates from the underlying uterine attachment
premature separation of the normally implanted placenta

26. ABRUPTIO PLACENTA Degree of Detachment: Partial Complete As to Onset
Acute
Chronic  
As to Type
External hemorrhage – bet. the membranes and uterus
Concealed hemorrhage – retained bet the detached placenta and uterus
Marginal sinus rupture – limited to the edge

27. ABRUPTIO PLACENTA: Risk Factors
Chronic HPN
Increased age and parity
Preeclampsia
PROM
Thrombophilias
Maternal trauma
Prior abruption
Smoking
Cocaine use
Uterine leiomyoma

28. ABRUPTIO PLACENTA: Signs & Symptoms
Vaginal bleeding* - 80%
Abdominal or back pain and uterine tenderness - 70%
Fetal distress* - 60%
Abnormal uterine contractions (eg, hypertonic, high frequency)* - 35%
Idiopathic premature labor - 25%
Fetal death - 15%

29. More common <19 or > 35 28 1/7 wks AOG ✔ 2nd & 3rd trimester
Salient Features
Abruptio Placenta
Placenta Previa
PPROM
38 yo
More common > 35
More common <19 or > 35
28 1/7 wks AOG ✔
2nd & 3rd trimester
Before 37 weeks
Acute
Vaginal bleeding
magnitude of blood loss
duration
Variable
Continuous
Often ceases w/in 1-2 hrs
Moderate  profuse
Sudden gush of
Variable quantity
of clear or slightly turbid, nearly colorless liquid
Red (bright)
Painful
UTZ Findings
abnormal placentation
Oligohydramnios
(-) fetal heart tone
Internal Exam:
3 cm cervical dilatation, 50% effaced, cephalic presentation, floating, (+) BOW
Pooling of blood
Leaking bag of water
Asst’d Hx
Most common etiology: maternal HPN
none
Asst’d w/ other obstetric complications: multifetal gestation, breech, chorioamnionitis

30. ABRUPTIO PLACENTA: Diagnosis
Clot formation retroplacentally
Ultrasonography and doppler imaging
Non-specific markers (thrombomodulin) – significantly elevated

31. ABRUPTIO PLACENTA
Hemorrhage into the decidua basalis ↓ Decidua splits (thin layer adherent to the myometrium) Decidual hematoma Separation, compression and destruction placenta Examination of freshly discovered organ: circumscribed depression measuring few cms in diameter on its maternal surface and covered by dark, clotted blood

32. ABRUPTIO PLACENTA: Management
Institute crystalloid fluid resuscitation for the patient (D5LR or D5W)
Monitor and control of BP, PR, RR, urinary output
Blood samples drawn for baseline hematocrit, coagulation studies, blood typing, and crossmatching
Treatment of associated DIC involves delivery of the fetus and placenta, restoration of maternal blood volume, and correction of coagulation with the use of blood components

33. ABRUPTIO PLACENTA Vaginal Delivery Cesarean Delivery fetus is dead
live and mature fetus
if vaginal delivery is not imminent

34. ABRUPTIO PLACENTA: Complications
Couvelaire uterus
extravasation of blood into the uterine musculature and beneath the uterine serosa  blue or purple
Acute Renal Failure
massive hemorrhage  impaired renal perfusion
Consumptive Coagulopathy