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OB-GYN CASE REPORT

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

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OB-GYN CASE REPORT

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  1. 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

  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, 28-30 days • Duration: 3-4 days • Amount: 1-2 pads/days • Sx: none Sexual History • Coitarche: 17 yo with her husband • (-) STDs

  10. OBSTETRIC HISTORY

  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,tonguemidline, (-) 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; (+) lineanigra, (+) striaegravidarum • 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) • additional 1 “u” of pRBC was transfused

  22. LABORATORY TESTS

  23. LABORATORY TESTS

  24. LABORATORY TESTS

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

  30. ABRUPTIO PLACENTA Hemorrhage into the deciduabasalis ↓ 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

  31. 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

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

  33. ABRUPTIO PLACENTA: Complications • Couvelaireuterus • 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

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