OB-GYN CASE REPORT

OB-GYN CASE REPORTKatrina Mae RamosSBC Medicine 2012GEN 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

HISTORY OF PRESENT PREGNANCYLMP: December 4, 2011AOG: 28 1/7 wks

HISTORY OF PRESENT PREGNANCYANTENATAL HISTORY4 PNCUs at local health centerDaily multivitamins intake with FeSo4Good diet with regular intake of milk and water

REVIEW OF SYSTEMSGeneral Survey: (-) weight gain, fever, chills, Skin: (-) rashes, pruritusHead and Neck: (-) headacheCNS: (-) loss of consciousness, nausea CVS: (-) easy fatigability, palpitationsRespiratory: (-) difficulty of breathing, chest pain, cough, hemoptysisGIT: (-) vomiting, polydipsia, vomiting, dysphagiaGUT: (-) polyuria, diarrhea, constipation, dysuria, hematuriaMusculoskeletal: (+) pelvic pain, (+) bipedal edema

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

FAMILY HISTORY PERSONAL & SOCIAL HISTORYMaternal & Paternal: u/r

Personal/Social History: u/r

MENSTRUAL & SEXUAL HISTORYMenarche : 14 yoInterval: regular, 28-30 daysDuration: 3-4 daysAmount: 1-2 pads/daysSx: none

Sexual HistoryCoitarche: 17 yo with her husband(-) STDs

OBSTETRIC HISTORYGravidaYearTermPlace of DeliveryComplicationsG1 1994FT (NSD)home(-)G21996FT (NSD)home(-)G32011Present PregnancyCONTRACEPTIVE HISTORY nonePHYSICAL EXAM: General Surveyconscious, coherent, ambulatory, NICRD

Vital Signs:BP: 140/110 mmHgHR: 92 bpmRR: 18Temp: 37.1CPHYSICAL EXAM: Head & NeckSKIN: good skin turgor, (-) clubbing and cyanosisHEENT: Head: normocephalicEyes: not bulging or protruding, pale palpebral conjunctiva, anicteric sclera,Ears: (-) visible masses, tenderness, dischargeNose: symmetrical, midline septum, no nasal flaringThroat: moist oral mucosa, no swelling,tongue midline, (-) TPCNeck: supple neck, trachea on midline, thyroid is not enlarged, (-) LADPHYSICAL EXAM: ThoraxInspection: no supraclavicular or intercostal retractions, (-) use of accessory muscles, no masses, lesions, Palpation: (-) tenderness, symmetrical chest expansionPercussion: resonantAuscultation: clear breath sounds

PHYSICAL EXAM: CVSInspection: no visible pulsesPalpation: AB palpated at 5th ICS LMCL, (-) heaves/thrillsAuscultation: normal rate, regular rhythm, no murmursPHYSICAL EXAM: AbdomenInspection: abdomen globular; (-) visible pulsations, dilated veins; (+) linea nigra, (+) striae gravidarumAuscultation: NABS, (-) organomegaly, FHT: not appreciated by stet & dopplerPalpation: FH=28 cm

PHYSICAL EXAM: PelvicInternal Exam (IE): 3 cm cervical dilatation, 50% effaced, cephalic presentation, floating, (+) BOW

EXTREMITIES: (+) pallor, (+) bipedal edema, no cyanosis, +2 pulses on both extremities

ADMITTING DIAGNOSISIUFD 28 1/7 wks AOG CIBL G3P2 (2002) Abruptio Placenta sec to PES

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

19COURSE IN THE WARDSJune 19, 2011 (Date of Admission)NPO, vital signs monitoring q1, IFCDiagnostics ordered: CBC with APC & BT, PT/PTT, CT & BT, UA, BUN, Crea, AST, ALT, LDH, Na, K, ClMeds ordered: MgSO4, Hydra 5mg TIV q20 mins (>160/100)Internal Exam (IE): 4 cm, 60% effaced, st. -2, (-) BOW after 2 hrshypertensive; other vital signs were stableFor LTCS I + BTL7:30 PM s/p NSDIVF with oxytocinadvised to start oral meds: Cefuroxime, Mefenamic Acid, Methyldopa, FeSo4

20COURSE IN THE WARDSJune 20, 2011 (Day 1 Post-Op)BP: 120/90; stable vital signs repeat laboratory test was done2 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)additional 1 u of pRBC was transfused

21CBC ResultsJune 19 (Pre-Op)June 20 (Day 1 Post-Op)June 22 (Day 3 Post-Op)RBC2.20 (L)2.75 (L)3.07 (L)Hemoglobin59 (L)80 (L)89 (L)Hematocrit0.18 (L)0.23 (L)0.27 (L)WBC count26.4 (H)38.4 (H)19.2 (H)Neutrophils0.898 (H)0.883 (H)NLymphocyte0.070 (L)0.072 (L)0.197 (H)LABORATORY TESTSLABORATORY TESTSCoagulationJune 19 (Pre-Op)June 21 (Day 2 Post-Op)Prothrombin Time12.39.1 (L) PT INR1.020.76 PT % Activity72.8176.4APTT35.234.9LABORATORY TESTSBlood ChemistryGlucose3.42 (L)BUN3.07Crea73.91 mmol/LAST53 (H)Na136K3.4 (L)Cl101Mg0.88AST (06/20/11)48 (H)ABRUPTIO PLACENTAaccidental hemorrhageIncidence: 1/100-1/200 deliveriesCommon cause of intrauterine fetal demiseOccurs when all or part of the placenta separates from the underlying uterine attachment premature separation of the normally implanted placenta

25ABRUPTIO PLACENTADegree of Detachment:Partial Complete

As to OnsetAcute Chronic

As to TypeExternal hemorrhage bet. the membranes and uterus Concealed hemorrhage retained bet the detached placenta and uterusMarginal sinus rupture limited to the edge

26ABRUPTIO PLACENTA: Risk FactorsChronic HPNIncreased age and parityPreeclampsiaPROMThrombophiliasMaternal traumaPrior abruptionSmokingCocaine useUterine leiomyoma

ABRUPTIO PLACENTA: Signs & SymptomsVaginal 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%Salient FeaturesAbruptio PlacentaPlacenta PreviaPPROM38 yoMore common > 35More common 3528 1/7 wks AOG2nd & 3rd trimester2nd & 3rd trimesterBefore 37 weeksAcuteVaginal bleedingmagnitude of blood lossdurationVariableContinuousVariableOften ceases w/in 1-2 hrsModerate profuseSudden gush ofVariable quantityof clear or slightly turbid, nearly colorless liquidRed (bright)PainfulUTZ Findingsabnormal placentationOligohydramnios(-) fetal heart toneInternal Exam:3 cm cervical dilatation, 50% effaced, cephalic presentation, floating, (+) BOWPooling of bloodLeaking bag of waterAsstd HxMost common etiology: maternal HPNnoneAsstd w/ other obstetric complications: multifetal gestation, breech, chorioamnionitis ABRUPTIO PLACENTA: DiagnosisClot formation retroplacentallyUltrasonography and doppler imagingNon-specific markers (thrombomodulin) significantly elevated

30ABRUPTIO PLACENTA Hemorrhage into the decidua basalisDecidua splits (thin layer adherent to the myometrium)Decidual hematomaSeparation, compression and destruction placentaExamination of freshly discovered organ:circumscribed depression measuring few cms in diameter on its maternal surface and covered by dark, clotted bloodABRUPTIO PLACENTA: ManagementInstitute crystalloid fluid resuscitation for the patient (D5LR or D5W)Monitor and control of BP, PR, RR, urinary outputBlood samples drawn for baseline hematocrit, coagulation studies, blood typing, and crossmatchingTreatment of associated DIC involves delivery of the fetus and placenta, restoration of maternal blood volume, and correction of coagulation with the use of blood components32ABRUPTIO PLACENTAVaginal Deliveryfetus is dead

Cesarean Deliverylive and mature fetusif vaginal delivery is not imminent

ABRUPTIO PLACENTA: ComplicationsCouvelaire uterusextravasation of blood into the uterine musculature and beneath the uterine serosa blue or purple

Acute Renal Failuremassive hemorrhage impaired renal perfusion

Consumptive Coagulopathy

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