1. CASE PRESENTATION BUENO, KATHRYN A. 4MED San Beda College of Medicine

2. General Data: M. L. 34y/o G2P1 (1001) Housewife Right-handed Roman Catholic Montalban Rizal

3. Chief Complaint: “vaginal bleeding”

4. History of Present Illness: 3 hours PTC vaginal bleeding abdominal pain frequent uterine contractions (+) dizzy (-) fever, vomiting, cough, colds loss of consciousness no medications

5. 1 hour PTC vaginal bleeding persisted abdominal pain increased in frequency immediately rushed at QMMC-ER on April 13, 2011

6. History of Present Pregnancy LMP: August 12, 2010 AOG: 34 6/7 weeks by LMP EDC: May 19, 2011

7. Past Medical History HPN- 20 years old ; no maintenace medication (-) diabetes, renal, lung, heart diseases (-) surgeries, hospitalizations, allergies

8. Family History HPN-father (-) diabetes, heart, lung, kidney diseases

9. Personal and Social History Housewife Non-smoker Non-alcoholic beverage drinker (-) illicit drugs Diet unrestricted

10. Menstrual History 13 years old Regular cycle Moderate flow Lasts for 5 days Consumes 3 pads per day (+) dysmenorheal symptoms

11. Obstetric History Gravida:2 Parity:1 (1001) 1 st child – 2007, full term, NSD, lying in at Montalban Rizal, (-) complications

12. Contraceptive History (-) birth control method

13. Review of Systems (-) headache, blurring of vision (-) dyspnea (-) chest pain, palpitations (-) frequency, dysuria

14. Physical Examination General Survey: The patient is conscious, coherent, ambulatory not in cardiorespiratory distress. Vital signs: BP 120/90 RR-20 HR-72 bpm T-36.5C

15. Skin: Nails without clubbing, cyanosis. HEENT: Head is normocephalic, atraumatic and no scar. Hair is evenly distributed. Scalp without lesions. Conjunctiva is pink, sclera is anicteric. Hearing is good, no ear discharge and no pain. No visible masses or ulcerations. Nasal mucosa pink. No sinus tenderness. No masses or polyps. Oral mucosa pink. Dentition good. Tongue midline. No exudates.

16. Neck: Neck supple. Trachea midline. No lymphadenopathy. Thorax and lungs: No scars, masses, lessions and tenderness. Thorax is symmetric with equal expansion. Lungs resonant in all fields. Breath sounds is vesicular in all lung fields. Equal fremitus: no bronchophony, egophony or whispered pectoriloquy.

17. Cardiovascular: No scars, masses, lessions and tenderness Regular rate and rythmn Good S1 and S2. S1 is louder in apex and S2 is louder at the base. No murmurs or extra sounds.

18. Abdomen: No masses, lessions, or tenderness with a 5cm vertical scar at linea alba. Well coaptated wound with no discharge. Abdomen is flat with normoactive bowel sounds (24/min). It is soft and tymapnitic upon percusssion. Liver span is 6 cm in the right midclavicular line. Spleen and kidneys are non-palpable.

19. Extremities: Warm without edema. Muskuloskeletal: Good range of motion in hands, wrists elbows, shoulders, knees, hips, ankles.

20. Admitting Diagnosis G2P1 (1001) Intrauterine Fetal Death (IUFD) 34 6/7 weeks AOG by LMP NIL T/C Abruptio Placenta

21. Course in the Wards Patient was admitted inserted with IV fluids (D5LR) administered MgS04 4 gram deep IM on each buttock (then 5 gram IM q6 24 hour post-partum) NSD but had uterine atony after delivery of the placenta underwent TAHBSO and bilateral hypogastric artery ligation due to postpartum hemmorhage 3 units of PRBC were transfused

22. Oral Medications: FeSo4 1 tab TID Amlodipine 10 mg tab. BID Essentiale 1 cap TID Clonidine 75 mg tab. For BP> 160/100 Mefenamic Acid 500 mg

23. IV medications: Cefuroxime 750 mg IV q8 Tranexemic Acid 1 gram q8 Furosemide 20 mg q12 Vitamin K 1 ampule q8

24. Laboratory exam results: CBC (April 20, 2011) ResultNormal Value RBC3.39 (L)3.8-5.1 Hemoglobin9 (L)11-16 g/dl Hematocrit0.30 (L)0.36-0.47 MCV91.278-98 fL MCH30.427-35 pg MCHC33.331-37% PlateletAdequate150,000-400,000 WBC17.2 (H)3.8-11 Neutrophils0.6050-81% Lymphocytes0.4014-44%

25. Clinical chemistry results (April 16, 2011) ResultNormal Vaue Creatinine56.8353-115 BUN5.132.5-6.40 Na138136-145 K33.5-5.1 Cl10597-107

26. Abruptio Placenta The separation of the placenta from its site of implantation after the 20 th week of pregnancy and before the delivery of the fetus.

27. Classification As to extent: Total Partial As to onset: Acute abruption Chronic abruption

28. As to type: External Concealed Marginal sinus rupture

30. Risk factors Increased age and parity Preeclampsia Chronic hypertension Preterm ruptured membranes Cigarette smoking Thrombophilias Cocaine use Prior abruption Uterine leiomyoma Trauma

31. Pathophysiology

34. Signs and symptoms Vaginal bleeding Uterine tenderness or back pain Fetal distress High frequency contractions Hypertonus Idiopathic preterm labor Dead fetus

35. Diagnosis Clot formation retroplacentally Ultrasonography and doppler imaging MRI Non-specific markers

36. Management Institute crystalloid fluid resuscitation for the patient (D5LR or D5W). Monitor BP, FH, pulse rate, respiratory rate, fluid intake and urinary output. Type and crossmatch blood. Request for CBC, including platelet count, plasma fibrinogen, fibrin degradation products and partial thromboplastin time. If plasma level is critical – administer fibrinogen using cryoprecipitate If platelet count is less than 50,000 ml, 6-8 platelet packs are transfused.

37. Delivery Vaginal Cesearian

38. Complications Couvelaire uterus Acute Renal Failure Consumptive Coagulopathy

39. Thank You!!!