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OBSTETRICS-GYNECOLOGY CASE PRESENTATION

OBSTETRICS-GYNECOLOGY CASE PRESENTATION. YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino Memorial Medical Center June 28, 2011. GENERAL DATA. J.M. 40 year-old female M arried R esiding at Quezon City

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OBSTETRICS-GYNECOLOGY CASE PRESENTATION

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  1. OBSTETRICS-GYNECOLOGY CASE PRESENTATION YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino Memorial Medical Center June 28, 2011

  2. 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

  3. CHIEF COMPLAINT • Labor pain

  4. 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

  5. 2 hours after consult • NSD to a live baby boy • Blood loss (400-500 cc) •  RR

  6. 3 hours after consult • Blood loss(300 cc) • Pale palpebralconjunctivae • Pale nail beds • Tachycardiac • Persistence and progression  Immediate intervention

  7. REVIEW OF SYSTEMS • June 19, 2011 • Unremarkable

  8. 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

  9. FAMILY HISTORY • Cancer - Mother • (-) Diabetes Mellitus, thyroid diseases, cardiac diseases, pulmonary diseases, renal diseases

  10. 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

  11. OBSTETRIC HISTORY • G10P10 (10-0-0-10)

  12. LMP of last pregnancy • September 22, 2010 • AOG • 38 weeks 4/7 by LMP • EDC • June 29, 2011

  13. ANTENATAL HISTORY • 2 prenatal check-ups at health center • No prenatal diseases and infections • Transabdominal ultrasound – 3rd trimester • No abnormalities

  14. MENSTRUAL HISTORY • Menarche - 12 y/o • Regular • Duration - 4-6 days • Interval - 28-30-days • Moderate amount (2-3 pads/day) • No dysmenorrhea/headache

  15. SEXUAL HISTORY • First coitus – 18 y/o • 1 sexual partner • No dysparenuria, post-coital bleeding, history of sexually transmitted diseases

  16. CONTRACEPTIVE HISTORY • 1990 – 1994 - Trust OCPs, discontinued • 1996 – present - Coitus interruptus

  17. 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: Anictericsclerae, pink palepebral conjunctiva • Cardiovascular: Adynamicprecordium, normal rate, regular rhythm • Abdomen: Round, FHT auscultated at 140s/minute on left lower quadrant

  18. Internal Exam: • Cervical dilatation: 7-8 cm • Effacement: 70 % • Presentation: Cephalic • Station: -2 • (+) Bag of Water

  19. 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 • Adnexaeare clear

  20. Estimated Fetal Weight: 3448 grams Impression: Pregnancy, 37 weeks and 6 days gestational age

  21. LABORATORY TESTS • June 19, 2011

  22. June 20, 2011

  23. June 20, 2011

  24. June 21, 2011

  25. June 21, 2001

  26. June 21, 2011

  27. June 22, 2011

  28. June 23, 2011

  29. 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 • Cefalexin500 mg/capq 8° x7 days • Mefenamicacid 500 mg/capq 6°, PRN for pain • CXR PA view, Na, K, Cl, AST, ALT, LDH, UA • NPO

  30. 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 • Ampicillin2 grams/IV, (-) ANST • 1 unitVoluven

  31. Underwent emergency Total Abdominal Hysterectomy under subarachnoid block • Vital signs - stable • 2 units of PRBCs - transfused • Blood loss intra-op - 800-900 cc

  32. Ketorolac30 mg IV loading, then 15 mg IVq 6° x4 doses (-) ANST • Tramadol150 mg loading then Tramadol drip 300 mg in 500 cc D5W at 21 gtts/min • Omeprazole40 mg IV OD while on NPO • Metoclopramide10 mg PRN for vomiting • Ampicillin1 gram IVq 6° (-) ANST • Metronidazole500 mg IVq 8° x3 doses (-)ANST • Cconsciousand coherent, with pallor. UO - adequate

  33. June 21, 2011 and June 22, 2011 • Same management • June 23, 2011 • Hemoglobin and hematocrit - slightly below baseline • Clearance for possible discharge

  34. 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

  35. 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

  36. 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.

  37. Predisposing factors: • high parity • precipitous or prolonged labor • general anesthesia • overdistendeduterus (macrosomia, hydramnios, multifetalpregnancy) • oxytocinaugmentation or induction of labor • history of PPH • amniotic fluid embolism • magnesium sulfate in laboring patients • constant kneading and squeezing

  38. 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

  39. 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, hemolysisd/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

  40. MANAGEMENT • fundal massage is indicated • 20 units of oxytocin in 1 L of LR or PNSS, IV, 10 ml/min • oxytocinshould 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

  41. if unresponsive to multiple administrations oxytocics: • bimanual uterine compression and fundalmassage • 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)

  42. ligation of arteries • B-Lynch suturing of uterus

  43. Intractable uterine atonyhysterectomy

  44. Thank You.

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