OBSTETRICS-GYNECOLOGY CASE PRESENTATION
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Transcript of OBSTETRICS-GYNECOLOGY CASE PRESENTATION
OBSTETRICS-GYNECOLOGY CASE PRESENTATION
YAMANAKA, Mariko Jennifer L.San Beda College of Medicine
Department of Obstetrics and GynecologyQuirino Memorial Medical Center
June 28, 2011
GENERAL DATA
• J.M.• 40 year-old female• Married• Residing at Quezon City• Seen for the 1st time at the Quirino Memorial
Medical Center-OB-Emergency Room on June 19, 2011
CHIEF COMPLAINT
• Labor pain
HISTORY OF PRESENT ILLNESS
• 5 hours PTA• Abdominal pain
• start from the back running towards her umbilicus• contractions lasting for less than 5 minutes (2x in
5 minutes)• Streak of blood form her vagina
• Persistence of the pain Consult
• 2 hours after consult• NSD to a live baby boy • Blood loss (400-500 cc)
• RR
• 3 hours after consult• Blood loss (300 cc)• Pale palpebral conjunctivae• Pale nail beds• Tachycardiac
• Persistence and progression Immediate intervention
REVIEW OF SYSTEMS • June 19, 2011
• Unremarkable
PAST MEDICAL HISTORY
• No previous surgeries/hospitalizations• No known allergies to food/medications • Immunizations unrecalled• Chicken Pox – elementary • No known co-morbid illnesses• No history of hypertension, Diabetes Mellitus,
Pulmonary Tuberculosis, cancer, asthma
FAMILY HISTORY • Cancer - Mother• (-) Diabetes Mellitus, thyroid diseases, cardiac
diseases, pulmonary diseases, renal diseases
PERSONAL AND SOCIAL HISTORY
• High-school graduate• Housewife• Lives with her husband and 9 children• Nonsmoker, non-alcohol beverage drinker• Denies illicit drug use• Diet - fish, vegetables, and rice• Water source - NAWASA
OBSTETRIC HISTORY • G10P10 (10-0-0-10)
Year Mode of Delivery Place Gender Complications
G1 1990 NSD QMMC Female (-)
G2 1992 NSD QMMC Male (-)
G3 1994 NSD QMMC Female (-)
G4 1996 NSD QMMC Female (-)
G5 1997 NSD QMMC Male (-)
G6 2001 NSD QMMC Female (-)
G7 2005 NSD QMMC Male (-)
G8 2007 NSD QMMC Male (-)
G9 2009 NSD QMMC Female (-)
G10 2011 NSD QMMC Male (-)
• LMP of last pregnancy• September 22, 2010
• AOG• 38 weeks 4/7 by LMP
• EDC• June 29, 2011
ANTENATAL HISTORY • 2 prenatal check-ups at health center• No prenatal diseases and infections• Transabdominal ultrasound – 3rd trimester
• No abnormalities
MENSTRUAL HISTORY • Menarche - 12 y/o• Regular• Duration - 4-6 days• Interval - 28-30-days • Moderate amount (2-3 pads/day)• No dysmenorrhea/headache
SEXUAL HISTORY • First coitus – 18 y/o • 1 sexual partner • No dysparenuria, post-coital bleeding, history
of sexually transmitted diseases
CONTRACEPTIVE HISTORY
• 1990 – 1994 - Trust OCPs, discontinued• 1996 – present - Coitus interruptus
PHYSICAL EXAMINATION
• June 19, 2011 – Upon Admission• BP: 110/70 mmHg, supine PR: 80 bpm, regular• RR: 18 breaths/min Temp: 36.8 C, per axilla • Conscious, coherent, ambulatory, not in cardio-
respiratory distress• HEENT: Anicteric sclerae, pink palepebral conjunctiva• Cardiovascular: Adynamic precordium, normal rate,
regular rhythm• Abdomen: Round, FHT auscultated at 140s/minute on
left lower quadrant
• Internal Exam: • Cervical dilatation: 7-8 cm• Effacement: 70 %• Presentation: Cephalic• Station: -2• (+) Bag of Water
DIAGNOSTIC EXAMINATIONS
• June 6, 2011• OBSTETRIC TRANSABDOMINAL ULTRASONOGRAPHY
• Uterus is regularly enlarged• Single alive fetus, male• Cephalic presentation• Fetal heart rat e-142 bpm• Absence of gross fetal abnormality• Normal Amniotic fluid volume• RUQ- 3.0 cm, LUQ- 3.4 cm, RLQ- 4.0 cm, LLQ- 3.0 cm = 13. 4
cm• Anterior, high-lying, with grade 2 maturity placenta• Adnexae are clear
Fetal Biometry: Measurement: Age of Gestation:
Biparietal Diameter 9.3 cm 37 weeks and 1 day
Femur Length 7.4 cm 38 weeks and 1 day
Abdominal Circumference 34.1 cm 38 weeks and 2 days
Head Circumference 33.5 cm 37 weeks and 6 days
Estimated Fetal Weight: 3448 grams Impression: Pregnancy, 37 weeks and 6 days gestational age
LABORATORY TESTS • June 19, 2011
Result Reference Range
RBC Low 3.66 4.20-5.40
Hemoglobin Low 105 120-160
Hematocrit Low 0.32 .36-.47
• June 20, 2011Result Reference Range
RBC Low 3.33 4.20-5.40
Hemoglobin Low 99 120-160
Hematocrit Low 0.30 .36-.47
Result Reference Range
Hemoglobin Low 96 120-160
Hematocrit Low 0.28 .36-.47
• June 20, 2011
BLOOD TYPING AND CROSSMATCHING RESULTSBlood Type: ARh Group: +
• June 21, 2011Result Reference Range
RBC Low 2.92 4.20-5.40
Hemoglobin Low 85 120-160
Hematocrit Low 0.26 .36-.47
• June 21, 2001
BLOOD CHEMISTRY
Test Name Result Reference Range
Sodium Low 135 136-145
Potassium 4.1 3.4-5.1
Chloride 104 97-107
• June 21, 2011PT, PTT
Parameters Result Reference Range
Prothrombin Time 10.4 secs 10-14 secs
PT INR 0.87 INR
PT % Activity 119.2 %
PT Normal Control 12.0 secs 10-14 secs
APTT 38.8 secs 28-44 secs
APTT Normal Control 35.5 secs 28-44 secs
• June 22, 2011Result Reference Range
RBC Low 3.02 4.20-5.40
Hemoglobin Low 90 120-160
Hematocrit Low 0.27 .36-.47
• June 23, 2011Result Reference Range
RBC Low 3.86 4.20-5.40
Hemoglobin Low 102 120-160
Hematocrit Low 0.34 .36-.47
COURSE IN THE WARDS
• June 19, 2011• Gave birth via normal spontaneous delivery to a
baby boy• Oxytocin IM• Total blood loss (400-500 cc)
• 10 ”u” of oxytocin - incorporated in IVF• Cefalexin 500 mg/cap q 8° x 7 days • Mefenamic acid 500 mg/cap q 6°, PRN for pain• CXR PA view, Na, K, Cl, AST, ALT, LDH, UA • NPO
• June 20, 2011• Blood loss (300 cc) • Pale palpebral conjunctivae, pale nail beds, and
tachycardiac (110-120 bpm)• Hemoglobin and hematocrit (99, .030)• For emergency hysterectomy secondary to uterine
atony• Ampicillin 2 grams/IV, (-) ANST• 1 unit Voluven
• Underwent emergency Total Abdominal Hysterectomy under subarachnoid block
• Vital signs - stable• 2 units of PRBCs - transfused • Blood loss intra-op - 800-900 cc
• Ketorolac 30 mg IV loading, then 15 mg IV q 6° x 4 doses (-) ANST
• Tramadol 150 mg loading then Tramadol drip 300 mg in 500 cc D5W at 21 gtts/min
• Omeprazole 40 mg IV OD while on NPO• Metoclopramide 10 mg PRN for vomiting• Ampicillin 1 gram IV q 6° (-) ANST• Metronidazole 500 mg IV q 8° x 3 doses (-)ANST• Cconscious and coherent, with pallor. UO -
adequate
• June 21, 2011 and June 22, 2011• Same management
• June 23, 2011• Hemoglobin and hematocrit - slightly below
baseline• Clearance for possible discharge
SALIENT FEATURES • 40 year-old, female• G10P10 (10-0-0-10)• Blood loss of approximately 800 cc• Tachycardic• Pale palpebral conjunctiva• Pale nail beds• Low Hemoglobin and Hematocrit
DIAGNOSIS • G10P10 (10-0-0-10) PUFT, cephalic, delivered
via NSD to a live baby boy with AS 9, Postpartum Hemorrhage secondary to Uterine Atony, S/P Total Abdominal Hysterectomy by Subarachnoid Block
DISCUSSION • Uterine Atony is the failure of the uterus to
contract properly following delivery.
• Failure of contraction and retraction of the myometrium prevents hemostasis and leads to an increase in blood loss.
• Predisposing factors:• high parity• precipitous or prolonged labor• general anesthesia• overdistended uterus (macrosomia, hydramnios,
multifetal pregnancy)• oxytocin augmentation or induction of labor• history of PPH• amniotic fluid embolism• magnesium sulfate in laboring patients• constant kneading and squeezing
• Uterine Atony VS Vaginal Lacerations • based on the condition of the uterus• uterus - soft and boggy following infant and
placental delivery• once uterus is well contracted, but still (+)
bright-red bleeding lacerations
• Complications:• vary, depends on the range of degree of severity• Hypovolemia maternal hypotension, shock, acute
tubular necrosis, dilution coagulopathy, cardiac arrest, and death
• BT-related complications – BT reactions, hemolysis d/t ABO incompatibility, viral diseases (hepatitis & HIV infection), acute lung injury, transmission of bacterial endotoxin, transmission of parasitic agents, graft VS host disease, alloimmunization to blood products, and transfusion-related immunosuppression.
• shock, anemia, infection, kidney failure, or brain damage
MANAGEMENT • fundal massage is indicated • 20 units of oxytocin in 1 L of LR or PNSS, IV, 10
ml/min• oxytocin should never be given as an undiluted
bolus dose as serious hypotension or cardiac arrhythmias may follow
• ergot derivatives: methylergonovine .2 mg, IM• may cause hypertension
• prostaglandin: hemabate 250 grams, IM• contraindicated in asthmatic px•
• if unresponsive to multiple administrations oxytocics:
• bimanual uterine compression and fundal massage• begin blood transfusions• explore uterine cavity manually for retained placental
fragments or lacerations• thoroughly inspect the cervix and vagina after adequate
exposure• add a second large-bore intravenous catheter at the
same time as blood is given• insert a foley catheter to monitor urine output (good
renal perfusion measure)
•
• ligation of arteries• B-Lynch suturing of uterus
• Intractable uterine atony hysterectomy
Thank You.