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

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OB-GYN CASE REPORT Katrina Mae Ramos SBC Medicine 2012 Slide 2 GEN DATA and CHIEF COMPLAINT L.C., a 38 yo G 3 P 2 (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 Slide 3 HISTORY OF PRESENT PREGNANCY LMP: December 4, 2011 AOG: 28 1/7 wks Slide 4 HISTORY OF PRESENT PREGNANCY Few hours PTA Moderate bloody vaginal discharge; (+) hypogastric pain (Gr. 5/10) An hour PTAProfuse bloody vaginal discharge Slide 5 ANTENATAL HISTORY 4 PNCUs at local health center Daily multivitamins intake with FeSo 4 Good diet with regular intake of milk and water Slide 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 Slide 7 PAST MEDICAL HISTORY (+) HPN 2011 (-) DM, heart dse, PTB, anemia (-) prior surgery, trauma, blood transfusions (-) allergies to food or meds Slide 8 FAMILY HISTORY PERSONAL & SOCIAL HISTORY Maternal & Paternal: u/r Personal/Social History: u/r Slide 9 MENSTRUAL & SEXUAL HISTORY Menarche : 14 yo Interval: regular, 28-30 days Duration: 3-4 days Amount: 1-2 pads/days Sx: none Sexual History Coitarche: 17 yo with her husband (-) STDs Slide 10 OBSTETRIC HISTORY GravidaYearTermPlace of Delivery Complications G1G1 1994FT (NSD)home(-) G2G2 1996FT (NSD)home(-) G3G3 2011Present Pregnancy Slide 11 CONTRACEPTIVE HISTORY none Slide 12 PHYSICAL EXAM: General Survey conscious, coherent, ambulatory, NICRD Vital Signs: BP: 140/110 mmHg HR: 92 bpm RR: 18 Temp: 37.1C Slide 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 Slide 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 Slide 15 PHYSICAL EXAM: CVS Inspection: no visible pulses Palpation: AB palpated at 5 th ICS LMCL, (-) heaves/thrills Auscultation: normal rate, regular rhythm, no murmurs Slide 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 Slide 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 Slide 18 ADMITTING DIAGNOSIS IUFD 28 1/7 wks AOG CIBL G 3 P 2 (2002) Abruptio Placenta sec to PES Slide 19 Plan: Trial of Labor Date of Operation: June 19, 2011 Post-Op Diagnosis: G 3 P 3 (2102) IUFD 28 1/7 wks AOG del via NSD to a dead boy, Abruptio Placenta, PES Slide 20 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 Slide 21 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) additional 1 u of pRBC was transfused Slide 22 Slide 23 Slide 24 Slide 25 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 Slide 26 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 Slide 27 Chronic HPN Increased age and parity Preeclampsia PROM Thrombophilias Maternal trauma Prior abruption Smoking Cocaine use Uterine leiomyoma Slide 28 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% Slide 29 Salient FeaturesAbruptio PlacentaPlacenta PreviaPPROM 38 yoMore common > 35More common 35 28 1/7 wks AOG 2 nd & 3rd trimester 2 nd & 3 rd trimester Before 37 weeks Acute Vaginal bleeding magnitude of blood loss duration Variable Continuous Variable 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 Findingsabnormal placentationOligohydramnios (-) fetal heart tone Internal Exam: 3 cm cervical dilatation, 50% effaced, cephalic presentation, floating, (+) BOW Pooling of bloodLeaking bag of water Asstd Hx Most common etiology: maternal HPN none Asstd w/ other obstetric complications: multifetal gestation, breech, chorioamnionitis Slide 30 Clot formation retroplacentally Ultrasonography and doppler imaging Non-specific markers (thrombomodulin) significantly elevated Slide 31 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 Slide 32 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 Slide 33 Vaginal Delivery fetus is dead Cesarean Delivery live and mature fetus if vaginal delivery is not imminent Slide 34 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